Membership Application

First Name

Last Name

Phone *

Email *

Business Name

Website or Instagram Handle (optional)

What services do you offer?

What is your current business model? (dropdown)

What draws you to the Burleigh Health Hub space?

Which membership tier are you interested in?

How soon are you looking to start?

Upload Insurance Documents *

Upload Qualifications and any associations that you hold memberships with

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply.

Reply HELP for help or STOP to opt-out.

By submitting this application, I confirm that:

The information I have provided is true and accurate to the best of my knowledge
I understand that submission does not guarantee membership, and that all applications are subject to review
I have read and agree to the Membership Terms & Conditions and Branding & Promotion Guidelines
I agree to uphold the values of Burleigh Health Hub, including integrity, emotional safety, and respectful collaboration
If accepted, I understand I will be required to pay a $1000 refundable security bond and select a monthly membership tier

I acknowledge and agree to the above terms. *