Team Membership Agreement

I give permission to Living Love, LLC (DBA Medicine with Heart) to charge my card five hundred dollars ($500) per month for the Medicine with Heart Team Membership.
Payment Information:
Cardholder Name:
Card Number:  
Expiration Date (MM/YYYY):  
CVV (3 digit code on the back of the card):  
Zip Code:  
Charge Every:
Would you like?
The day of month you will be charged will be the day of signing up for your Medicine with Heart membership with the clinic. This will repeat on the same date of the month (i.e. the 3rd of each month if you signed up on the 3rd and paying monthly or the 3rd of the month six calendar months from signing up if paying every 6 months)
Total payment amount will be the amount selected above
The product(s) and/or service(s) sold with this agreement are likewise a sum of those that have been checked.
To cancel, contact: Anand Grace - Phone: 720-722-1143 | email: [email protected]
Membership includes up to one monthly coach session and every other month practitioner visit (on even months of membership i.e. month 2, 4, 6, etc.). Membership also includes between session support via messaging through the patient portal, optional access to educational videos, and optional webinars. The first practitioner visit requires that two months of membership dues are paid. For additional details of what is included in each membership level, please visit:
Terms of agreement
Cancellation requests must be received at least one week prior to next billing date or else cancellation will be processed the following billing period.
There are no refunds for membership amounts already paid. There are no guarantees in terms of outcome or results from working together. Membership benefits such as sessions do not roll over or accumulate for future use. You acknowledge and agree that you are solely responsible for the use of your Membership and the results attained from such use. Non-use is not grounds for a refund.

Additional terms apply to memberships. By signing this agreement you are agreeing to those terms. Please review additional membership terms at this website:
Patient Name:  
Todays Date:

Leave this empty:

Signature arrow sign here

Signature Certificate
Document name: Team Membership Agreement
lock iconUnique Document ID: f6eaafae140056b0bc634cbdb983479ff8aceab1
March 8, 2022 5:46 pm MSTTeam Membership Agreement Uploaded by Dr Miles Nichols - [email protected] IP