Carolina Concierge Care

I have engaged Carolina Geriatric Specialists, LLC, to provide non-covered, non-clinical amenities and benefits to me for an initial period of one-year beginning on May 2, 2024. I understand that this Agreement will renew automatically following the end of each one-year period unless I provide Carolina Geriatric Specialists, LLC with a written notice of non-renewal at least 30 days before the end of a renewal year. I further understand that I will be required to pay a yearly membership fee at the start of each renewal term for the non-covered services, amenities and benefits. As used in this Agreement, the term “Service Year” refers to the one-year period beginning on May 2, 2024 as well as every one-year renewal period thereafter.

$1,950/year = Individual
$3,510/year = Couple

Individuals (Required)

Price: $1,950.00

Hidden

Total members

(will be hidden, for logic only)

Couple's Discount

Price:

Total

This Agreement is for non-covered, non-clinical amenities and benefits as described in the Highlights & Details (H&Ds) 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 pro-rated 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 practice 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 or above, it will automatically renew for subsequent Service Years under the same payment terms, unless I notify the practice otherwise (or the practice notifies me) within 30 days of the next payment due date.

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 ZIP Code

How did you hear about our practice?(Required)

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Membership Agreement

Carolina Geriatric Specialists

1st Individual

2nd Individual

3rd Individual

1st Dependent (between the ages of 13 and 26)

2nd Dependent (between the ages of 13 and 26)

3rd Dependent (between the ages of 13 and 26)

4th Dependent (between the ages of 13 and 26)

5th Dependent (between the ages of 13 and 26)

6th Dependent (between the ages of 13 and 26)

7th Dependent (between the ages of 13 and 26)

Credit Card Details

ACH Option