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Amplifii Health Membership Form

* Required

Please complete this form in its entirety and with accurate and up-to-date information in order to activate your newly purchased Amplifii Health Subscription

Multi-line address
Please select your membership tier
Essential
Premium
Comprehensive

Essential = $85

Premium = $105

Comprehensive = $120

Are you including your spouse?

Essential = $70

Premium = $85

Comprehensive = $95

$25 for each child

Member Acknowledgments: Please check each of the below boxes, acknowledging each statement.

Consent to Communication: Please indicate how you would like AMPLIFII Health to communicate with you about your membership, appointments, billing, and program updates.
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