Concierge Agreement

1

Name* This field is required.

First Name

Last Name

2

Please choose a tier* This field is required.

Main Care $19/mo (not available for Dr. Karp, Dr. Celmer, or Dr. Klausmeyer)

Premier Care $49/mo

Signature Care $129/mo

Signature Family Plan $229/mo for two adults in the same household

Non-member $60 administration fee per visit

Self-pay patient (not using insurance, no member fee)

3

Number of Adults:* This field is required.

4

Name of other adult adding to plan* This field is required.

First Name

Last Name

5

Add a child for $19/mo?* This field is required.

YESNO

6

Add a child for $49/mo?* This field is required.

YESNO

7

Add child(ren) to plan* This field is required.

8

ICM Primary Doctor* This field is required.

9

ICM Primary Doctor* This field is required.

10

Payment* This field is required.

Credit Card Previously Authorized

New Credit Card

11

Please provide your credit card to the front desk if filling this out in the practice. Otherwise, we will contact you to collect credit card information through your Portal.

12

Last 4 Digits of Credit Card on File* This field is required.

13

I would like to pay for the year in full at a discounted rate ($255/annually).* This field is required.

YESNO

14

I would like to pay for the year in full at a discounted rate ($550/annually).* This field is required.

YESNO

15

I would like to pay for the year in full at a discounted rate ($1,515/annually).* This field is required.

YESNO

16

I would like to pay for the year in full at a discounted rate ($2,700/annually).* This field is required.

YESNO

17

Terms and Conditions* This field is required.

18

Signature* This field is required.By signing, I agree I have informed my doctor of everything listed.

19

Please verify you are human* This field is required.