This clinic is owned and operated by Brownell Chiro LLC
This clinic is owned and operated by XXXX and managed by XXXX
CANCELLATION OF MEMBERSHIP NOTICE
SECTION 1: To be Completed by Member
Today’s Date: Patient Name:
Phone: Email:
Reason for Cancellation:
Did the Wellness Coordinator discuss the benefits of a Flex Plan with you? Yes No
SECTION 2: Member Signature
Member may cancel his/her Wellness Plan Membership or Flex Plan Membership (HEREINAFTER, COLLECTIVELY REFERRED TO
AS “MEMBERSHIP PLAN”) upon providing this Cancellation of Membership Notice (THE “CANCELLATION NOTICE”) at The Joint
Chiropractic location at which Member maintains his/her MEMBERSHIP PLAN (the “Home Location”) and after meeting any payment
terms and conditions outlined in their APPLICABLE MEMBERSHIP PLAN. After submitting the Cancellation Notice, member can use
remaining visits until next month’s would-be billing date, if applicable (e.g., if a member is billed on the 8th of each month and he/she
cancels their membership on March 1st, the member will have until March 7th to use remaining visits).
Individual family members may cancel their membership, but cancellation by a family member will cause the family membership to
cease, unless there are at least two remaining family members. All Cancellation Notices must be signed and dated and sent by certified
mail, return receipt requested or be hand-delivered to the location at which Member maintains his/her membership at least 2 days prior
to next billing date to result in no further billing. The monthly membership fee(s) for some or all of the members of a Family Plan may
increase if one of the family members cancels his/her membership. The terms of this Cancellation Notice are subject to applicable state
laws, which will govern in the event of any conflicting terms.
A cancelled Wellness Plan may be reinstated within 60 days of cancellation by completing a Plan Reinstatement Form.
By signing below, the Member acknowledges that they understand and accept the cancellation terms, conditions and procedures stated
above, that the dates below have been explained to them and that upon termination of their Membership Plan, they will not receive any
further benefits of Membership. The Member acknowledges and agrees that they remain bound by the surviving provisions of their
Membership Agreement. They further hereby, irrevocably, jointly and severally release and hold harmless The Joint Corp., and their
successors, employees, franchisees, affiliates, agents, and assigns, from and against and in respect of any and all losses, costs,
expenses (including, without limitation, reasonable costs of investigation and defense and reasonable attorneys’ fees), claims, damages,
obligations, or liabilities, whether or not involving a third party claim (collectively, “Damages”), if and to the extent such Damages
associated with, arising under, or related to, the Member’s use of this Membership or the services and/or treatment the Member received
at a The Joint Chiropractic clinic.
Member Signature:
SECTION 3: To Be Completed by Clinic
Member Since / / Final ARB Date / /
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© 2022 THE JOINT CORP. ALL RIGHTS RESERVED.
