Membership Form

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Can you confirm that your are either the parent or the legal guardian of the following children and consent them to be part of this family membership? *

Yes I am the parent/legal guardian of the children (0-16y) listed below

Name of Child 1 *

First Name

Last Name

Date of birth *

Child 1

MM

DD

YYYY

Are the address and contact details the same as yours? *

Yes - Please skip to the next section: Child 2.

No - Please continue to fill in the details.

Address of Child 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Child 2 *

First Name

Last Name

Date of birth *

Child 2

MM

DD

YYYY

Are the address and contact details the same as yours? *

Yes - Please skip to the next section: Child 3 / Adult 2.

No - Please continue to fill in the details.

Address of Child 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Child 3 or Adult 2 *

The Family plan is either 1 adult and 3 children or 2 adults and 2 children.

First Name

Last Name

Date of birth *

Child 3 / Adult 2

MM

DD

YYYY

Are the address and contact details the same as yours? *

Yes - Please skip to the next section: Consent and Agreement.

No - Please continue to fill in the details.

Address of Child 3 or Adult 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Consent and declaration *

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used to provide appropriate medical care.

Agreement Confirmation and Acceptance *

I confirm that by clicking this box I acknowledge these terms and conditions¹, and that I have read, understood, and agree to be bound by the terms set out in this contract. I acknowledge that I have had the opportunity to seek independent legal advice. I understand that the membership is subject to approval by the clinic, and the agreement will only become effective once the clinic’s approval has been granted. No modifications or amendments to the terms will be valid unless agreed upon in writing by both parties. This contract will take effect on the date of the last signature or electronic confirmation, provided the clinic approves the membership.