2926 Sherwood Way, Suite 100
San Angelo, TX 76904
(325) 617-5552
wwwtheioint com
Date: February 8, 2023
Patient Name: Lynette Davis
Email Address:. lynettej.davis@yahoo.com
We understand that you have' requested to cancel your Wellness Plan. Before cancelling we
would like for you to consider moving to our FLEX PLAN. Our Flex Plan is designed for people
coming in once or twice per month. It is only $20 per month. This membership fee gives you
access to discounted per visit rates of $20 per visit. That breaks down to $40 for one visit per
month, $60 for two visits per month, etc. This is still a better deal than paying the $45 walk in
price every time you come in!
Decide to remain a member of The Joint? AWESOME! Please call our office at 325-617-5552
Flex Plan Pricing
NEW! Added flexibility to fit your busy lifestyle.
: Flex Plan (6 month minimum)
$20/month + $20 per visit
Low monthly access. Pay as you go.
Stretch your dollars further
with your Flexible Spending Account (FSA)
or Health Savings Account /HSA).
or email us to let us know that you would like to continue your membership with The Joint
Chiropractic and move over to the Flex Plan.
Still want to cancel? Please share your reason{s) with us and complete the Cancellation Form:
___ Can't afford the monthly fee
__ The hours don't work with my schedule
___ The wait times are too long
__I have moved. No Joint Chiro near me.
Other_____-'---------------------A cancelled Wellness Plan may be reinstated within 60 days of cancellation by completing a
Plan Reinstatement Form
THeJOlr1T
d1iropractic
CANCELLATION OF MEMBERSHIP NOTICE
SECTION 1: To be Completed b Member
8,._....._
2023_____.___
Today's Date:_._
.February
______
325-939-4175
_______ _____
Phone: ___
Lynette Davis
Patient Name: ____________
_
lynettej.davis@yahoo.com
_____________
Emall: __
extended -'--______________________
drive - 1hr away
ReesonforCsnceUa!lon: __________
_
Old the wenneu Coordina10r dlSCUS& Iha benefits of a Flex Plan wl!h you?
D Yes D
No
SECTION 2· Member Signature
Member may cancel his/her Wellness Plan Membem/lfll or Flex Plan Membership (HEREINAFTER, COLLECTIVELY REFERRED TO
Af!. "MEMBERSHIP PLAN")· upon providing this Cancellallon of Membership Notice (THE "CANCEUATION NOTICE") al The Joint
Chiropractic locaUan at which Member malntafns his/her MEMBERSHIP PLAN (the "Home lccalioni and after meeUng any payment
tenns and. conditions culllned In lhelr APPLICABLE MEMBERSAJP PLAN. Aller &Ubmllllng the Cancellation Notk:e, member can use
remaining visits until ·next month's would-be bllJlng dale, if applicable (e.g., If a member Is bllled en the 8th cf each manlh and he/she
cancels lheir membership en March 1st. Iha member will have·until Man:h 7th la usa remaining visits).
Individual famlly members may cancel their membelShlp, but cancelJallon by a ram11y member will cause the famlly membership la
cease, unless there are at least two remelnlng family members. All Cencellallon Nolices must ba signed and dated and sent by certified
mat� retum receipt requested er be hand-deilvered la the locallan at which Member malnlains his/her membership at least 2 days prior
ta next billing date to result In no further billing. The manlhly membsrshlp fea(s) for some or all of Iha members cf a Famtty Plan may
Increase If oneof the famDy membelll cancels his/her membership. Toe terms of this Cancellallon Notice are subject le appHcable stale
laws. which will gowm In the event of any ccnlllcllng tenns.
A cancelled Wellness Plan may ba reinstated within 60 d.eyscfcancellati011 by ccmpletlng a Plan Reinstatement Fomi.
By signing below, the Member acknaNledgea that they understand and acceptlhecanceUallon terms, conditions and procedures staled
above, that the dates below have been explained le them and that upon tennlnatlon of their Membership Plan. they will not receive any
further benefits of Membmshlp. The Member acknowledges and agrees that lhey remain bound by the survMng provl&lons of1helr
Membership Agreemenl. They fi.lrther hereby, Irrevocably, Jolnlly and severally release and hold harmless Toe Joint Corp., encl their
successors, employees, franchisees, aflillales, agents, and assigns. frcm and against and In l!ISPec! of any and all losses, costs,
expenses (Including, wtthoUt Hmllallon, raasonable costsof lnvestigallon and defense and reasonable attarneys' fees), clalms, damages,
obllgallons. or liabilities. whether er not Involving a third party clalm (collectively, "DlllllBges1, If and le Iha extent such Damages
assccialedwith, arising under, or IBla!ad to, the Member's usa of lhls Membership or the sel1lices and/orlreatment Iha Member received
at a The Joint Chiropractic dlnlc.
Member Signature: _______________
SECTION 3: To Be Completed by Clinic
MemberSince,_,_/-�''----
FlnalARB Date,__--L,/ ___,1'-_
CACSll o 1HEIOIH?CHtll0fRAC'IIC:. CANCllumaNOFMEMBlllSHIPNCmCE
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