Membership application – Gold Elite

INDIVIDUAL: $79 per month + applicable taxes

FAMILY: $119 per month + applicable taxes

Membership Type* :

IndividualFamily

Referred By :

Personal Information:

Full Name (FIRST/LAST) *

Date of Birth (YYYY-MM-DD) *

Gender *

Preferred Email *

Preferred Phone *

Home Address (NUMBER/STREET)*

City *

Province *

Postal Code *

Company Information (If applicable):

Name of Company

Company Address

City

Province

Postal Code

Spouse/Partner (Family plan only):

Full Name (FIRST/LAST) *

Date of Birth (YYYY-MM-DD)

Gender

Preferred Email *

Preferred Phone

Dependents (Family plan only):

Do you have any dependents?: YesNo

* max four, up to age 25

Full Name
(FIRST/LAST)

Date of Birth
(YYYY-MM-DD)

Gender

Preferred Email
(Required for ages 18 and over)

Full Name

Date of Birth

Gender

Preferred Email

Billing frequency* :

MonthlyAnnual

Please note that in order to protect your financial information, we will send you a secure link to collect your credit card details and activate your membership.

Membership Terms and Conditions:

For the full terms and conditions, please click here

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

Signature (please type your full name) *

Date (YYYY-MM-DD) *

Advica Health™, a division of Royal VIP Health Options Inc.

QUESTIONS? CONCERNS? Please email Advica Health at info@advicahealth.com
Note: This application form and pricing replaces any previous Advica or VIP Health Options Inc. application forms.

Membership application – Gold Elite

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