Freeze Request Form

As part of our Freeze process we require a written notice and a few questions to provide us with important feedback that will help us with your freeze process. Your feedback is so important to us and we want to hear how we can better serve you in the future.

Full Name *

Email *

Why did you initially get started with a membership at EHP? *

How satisfied were you with your treatment plan? *

How informative was our staff and team of medical professionals? *

What is the reason you are deciding to freeze your membership? *

How long would you like to freeze your account for? (1-3 months) *

Do you have any additional feedback you would like to share?

I understand that my membership will be placed on hold and that there will be a $30 monthly charge. *

Yes, I understand

I understand that I will need to contact Eternity Health Partners to re-activate my membership without any re-enrollment cost. *

yes, I understand

We hope that you enjoyed your experience and will come back to see us soon! Thank you so much for visiting Eternity Health Partners