CBRC Health & Wellness Clinic Retainer Request (one request per account please)
Email address *
First and Last Name on Membership *
Phone Number *
By checking this box, I hereby request CBRC Health & Wellness Clinic (CBRC) place my membership on retainer status (billed at $15.00+tax/mo) due to the ongoing COVID-19 pandemic. I understand that being on freeze does not allow me to use the facility in any way. I hereby authorize CBRC to initiate any payment for any amounts I may owe via the financial institution and account I may have on file. If on draft, I hereby authorize CBRC to automatically collect payment until membership is cancelled by the agreed upon Terms of Membership already on file and agree to keep my payment information up-to-date. *
Required
Enter FULL NAME to acknowledge and agree to above *
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy