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. *
Enter FULL NAME to acknowledge and agree to above *
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy