VISION ALIVE -VIP TOTAL CARE Member

First Name

Last Name

Name of the person who referred you. If no one, just state n/a

Phone *

Email *

Address

Street Address

City

State

Country

Postal code

I agree that the VIP Membership is $45.00 monthly benefit package agreement.

VIP Total Care Benefits cover the entire family ( up to 8 family members) Membership Includes Therapy, video/phone doctor visits, counseling, pharmacy discounts, discounted prescriptions, lab discounts, financial consultations, attorney consulting, medical bill help, medical diagnosis support, discounted travel, spiritual guidance by our network of pastors, spiritual leaders and prayer team. Membership package will arrive by email.

Membership Optios

Monthly - $45.00

Semi- Annual - $270.00

Annual - $540.00

List the name of each person in your household that will be included in this family plan

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.

You agree to make the 1st payment in the amount of $45.00, $270.00 or $540.00at the submission of this form. You will also receive a separate link to pay the $30.00 enrollment fee and monthly installment agreement by our membership service monthly payment processor. *

Yes

You agree to make the 1st payment in the amount of $45.00, $270.00 or $540.00 as the initial payment. *

Yes