Membership Agreement Dr. Clint Flanagan If you have questions, please call my membership team Specialdocs Consultants at 555 555 55555. Step 1 of 4 25% I have engaged flanaganenroll.com (Company) and its physician Dr. Clint Flanagan, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one year beginning April 21, 2025. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide the Company with a written notice of non-renewal at least 30 days before the end of a Service Year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for these non-covered services, amenities, and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on the date above, as well as every one-year renewal period thereafter. $89/month = 18+ years $49/month = 0-17 years Individuals (18 and over)0123Individuals under 180123This field is hidden when viewing the formTotal members(will be hidden, for logic only)This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details document. I have read and understand this Agreement as well as the Highlights & Details and Frequently Asked Questions documents that are considered a part of this Agreement. I understand that this Agreement can be terminated upon 30 days written notice and that, if the Agreement is terminated, I may receive a prorated refund of the annual fee I paid, based on the number of days that have elapsed in the Service Year (which will be determined by the Company on a case-by-case basis). Such refund will be paid to me within 30 days after termination. Unless the Agreement is terminated as provided in the first paragraph of this Agreement above, it will automatically renew for subsequent Service Years under the same payment terms unless I notify the Company otherwise (or the Company notifies me) within 30 days prior to the next payment due date. 1st Individual 18 and overName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone Number(Required)Is this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 2nd Individual 18 and overName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 3rd Individual 18 and overName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail(Required) 1st Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 2nd Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 3rd Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerHormone Health ProgramDoes the patient want to enroll in our Hormone Health Program with Dr. Flanagan (additional cost of $1,200 annually). Note that this is a 12-month program. Yes Hormone Health Program Payment Schedule Quarterly: $300 Semiannually: $600 Annually: $1200 Daytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 4th Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 5th Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 6th Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail 7th Individual 18 and underName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemalePrefer Not to AnswerDaytime Phone NumberIs this a cell number?(Required) Yes No Cell Phone NumberEmail Payment MethodCardACHCredit Card DetailsYour card will be charged by Dr. Clint Flanagan.Credit Card Type(Required) Visa MasterCard AMEX Discover Card Number(Required)Card Number(Required)Expiration MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberExpiration Year2023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050Security Code(Required)Security Code(Required)Cardholder Name(Required)Billing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required)Consent(Required) I authorize Dr. Clint Flanagan to automatically charge my credit card the amount(s) indicated on this form. ACH OptionBilling Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Daytime Phone Number(Required)Bank Name(Required)Account TypeBusinessPersonalRouting Number(Required)Please Confirm Your Routing Number(Required)Account Number(Required)Please Confirm Your Account Number(Required)Consent(Required) I authorize Dr. Clint Flanagan to automatically pull from my bank account the amount(s) indicated on this form. Digital Signature(Required)Please type your initials to confirm this agreement.Is the home address different from billing address(Required) Yes No Home Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How did you hear about our practice?(Required)I am a Current PatientI am a Former PatientInsurance ProviderInternet SearchPatient ReferralPhysician ReferralPrint AdvertisingOtherPlease elaborate(Required)