The Wellness Institute: Virtual Membership

Primary Member Information

First Name

M.I.

Last Name

Address 1

Address 2

City

State / Province

Zip / Postal Code

Home Phone

Mobile Phone

OK to Contact Home Phone

OK to Contact Mobile Phone

Preferred Phone

Home

Mobile

OK to Contact Email?

Emergency Contact

Name

Phone

Birth Date

Gender

Male Female Other

Monthly Payment

$16.79

$5.89

Service	Down Payment	Recurring	Rollover	Visits
Member 1
Membership Dues	$0.00	$15.99	$0.00	0
Membership Dues	$5.61			0
Sub-Total	$5.61	$15.99
Tax	$0.28	$0.80
Total	$5.89	$16.79

Payments will then be processed on a Monthly basis there after.

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