MEMBERSHIP APPLICATION

Plan Type:
Name:
Date of Birth: Gender:

COMPANY INFORMATION:

Name of Company:
Title:
Address (NUMBER/STREET):
City: Province:
Postal Code: Preferred Phone #:
Preferred Email:*

PERSONAL INFORMATION

Home Address (NUMBER/STREET):
City: Province:
Postal Code:

Signature

Signature:*

Please type your Full Name

Date:

MEMBERSHIP TERMS AND CONDITIONS
The undersigned shall be voluntarily enrolled in the Advica Health program commencing as per Advica Health effective date guidelines. The listed membership rates are subject to change upon thirty 30 days’ written notice. These rates do not include coverage for or cost of medical treatment, Health Assessments, medications, travel, accommodations or any other overhead costs associated with managing a healthcare issue. Notwithstanding anything else to the contrary herein, the undersigned or Advica Health may cancel such membership, at any time and for any reason after the first (1st) anniversary date of the effective date upon at least thirty (30) days’ written notice delivered to the Advica Health team.

In the event that the undersigned fails to make any payment when due under the Advica Health program, and such payment is not made, in full, within thirty (30) calendar days after written notice is received of payment failure, Advica Health shall be entitled, in its sole and absolute discretion, to cancel and terminate the undersigned’s membership and any and all related coverage(s) or treatment(s) under the program, without further notice. As part of this application, and after being accepted as a member, the undersigned acknowledges and agrees that certain information shall be requested and provided, from time to time, concerning his or her personal health, financial and other private matters in connection with the Advica Health program. By signing and delivering this application, the undersigned agrees and consents to Advica Health or its authorized representatives collecting, using, sharing or otherwise disclosing such personal and private information for the purposes of such program and for no other purpose.

Advica Health acts only as a navigational assistant for health care professionals and a consolidator of service offerings from a series of third party service providers, who provide treatment and other services to the member as contemplated by the membership program (the “Service Providers”). By signing and returning this form, you acknowledge and agree that Advica Health and its employees, agents and authorized distributors are not responsible or liable in any manner for, and will be held harmless by you from any and all claims, demands, losses or damages that may arise from, the actions or omissions of the Service Providers as part of the plans, services and programs contemplated by this Membership Application.

I have read the above and agree to all terms and conditions.

Advica HealthTM, a division of Royal VIP Health Options Inc. QUESTIONS? CONCERNS? Please email Advica Health at info@advicahealth.com. Note: This registration form and pricing replaces any previous Advica or VIP registration forms. V.2019 (1)

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