Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ oneVfourth (1/4) of the Member Amenities Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇, President
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Payment Authorization; Execution. Program Member either (i) tenders together with this Agreement the Member Amenities Fee, or (ii) hereby authorizes Personalized Care Practice’s designee to ▇▇▇▇ oneVfourth one-fourth (1/4) of the Member Amenities Personalized Care Fee (that is, $ ) per calendar quarter (3 months) payable in advance to Program Member’s: CREDIT/DEBIT CARD Visa MC Discover AMEX CARDHOLDER NAME CARD NO. Program Member understands that credit card payments will be processed by Signature MD, Inc. and agrees to make payments by check payable to “SignatureMD”. This Agreement, including the attachments and exhibits, will be fully binding upon each Party and constitutes the entire agreement between the Parties in connection with the subject matter in this Agreement, and supersedes all prior agreements and understandings between the Parties, whether written or oral, which have been made before the execution of this Agreement. (Print Name) By: ▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇▇, PresidentMD
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