Membership Form | Amplifii

First name

Last name

Date of Birth

Email

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Billing Frequency

Please select your membership tier

Essential

Premium

Comprehensive

Are you including your spouse?

How many children?

$25 for each child

Please provide your children's names and dates of birth below in the following format: Last Name, First Name, MM/DD/YYYY. Separate each family member by clicking "enter". "Children" are defined as individuals 17 years or younger.

Example:

Smith, John, 03/01/2020

Smith, Jane, 05/01/2021

If someone helped you become an AMPLIFII Member, please list their name below or enter N/A

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

I understand that AMPLIFII Health Direct Primary Care is not health insurance.

I understand that participation in this program covers only the services included in my selected plan tier and does not guarantee coverage for services outside that tier.

I understand that accessing services not included in my plan may result in additional charges, and I am financially responsible for the additional charges.

I understand that specialist care, hospital services, emergency care, and other non-included services are not covered by this program unless specifically stated by the program.

I understand that program fees are due on a recurring basis to maintain active enrollment.

I understand that program eligibility and access to services may be suspended or terminated if payment is not received according to program terms.

I understand that it is my responsibility to notify AMPLIFII Health of changes to my contact information, household coverage, or payment information.

I acknowledge that I have received or been offered information describing membership benefits, limitations, and program terms.

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

Email

Phone

Text

Amplifii Health Membership Form

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