Monthly Wellness Memberships with Roshelle K. LeVa L.Ac. aka; Shae LeVa

True Blue $99.00 Includes one acupuncture
paid monthly

Healthy Green $166.00 Include two acupuncture
paid monthly

Rainbow Gold $244.00 Include three acupuncture
paid monthly

The words “you”” and “your” mean the member listed above, and the buyer signing below with respect to payment. The words “we” “our” and “us” refer to Northgate Center for Wellness, and our networked affiliates.

Monthly Payments: Your monthly membership term begins on (date) you sign the contract and ends in one year at the end of the signed month. This is a year contract and will automatically renew, and continue on a month-to-month basis until terminated in accordance with this agreement. You agree to pay monthly on the 1st day of the month until the contract has ended or is canceled. During the time you are in contract, you are protected against any price increases. After the year contract is over you have 30 days to renew the original contract before you are subject to any price increases. You will notify Shae LeVa via email of any changes in payment method, and commit to keeping accurate billing information during your contract time.

Sign below signifying you have read the contract and agreed to it.

Roshelle K. LeVa LAc, is licensed both in California and nationally for acupuncture, bodywork, herbs, and energy work. Her licenses and insurances are up to date. Roshelle K. LeVa LA.c complies with all HIPPA and acupuncture laws, and clean needle requirements. professional health providers who work with Roshelle K LeVa LAc. as an acupuncturist, will comply with local licensing and certification requirements. You understand that the services provided at shaeleva.com are not a replacement for emergency medical care, but are used as a preventive health measure to help keep you as healthy as possible. You understand that if the condition that you are seeking help for is outside Shae’s scope of practice, she will refer you to a suitable health care provider and that your membership benefits will not cover care outside of our office.

We reserve that right to collect on any one time any delinquent outstanding balances that have not been paid for any services provided, or for any payments owed. For purposes of identification and billing, you agree to provide us with current, accurate, complete, and updated information including your name, address, telephone number, and applicable payment data. You agree to notify us promptly of any changes in your information, including your payment data.

You understand that this agreement only entitles you to benefits set forth herein. This agreement does not apply to your family or any friends to use the benefits within the membership unless agreed upon and written on the contract. If someone else is written into the contract, they must sign all patient intake forms and agree to all terms and conditions of treatments offered by Shae LeVa before they may use the session. If the treatment is used by a minor, a representing adult must sign for them.

You are entitled to a copy of this agreement at the time you sign it. You may cancel this agreement any time before midnight of the third operating day after signing this agreement. Suppose you cancel this agreement within three days. In that case, you are entitled to a full refund for the amount remaining after deducting the regular non-member price of treatments you have received that were included in the membership contract upon signing. Refunds must be made within 30 operating days of receipt. All cancellations must be signed and dated within the notice. If you do not cancel within the three-day period, you shall be bound by all the terms of this agreement.

By signing this contract, you understand, acknowledge, agree, and hereby voluntarily accept all risk and responsivity with the services provided at shaeleva.com. You hereby waive all claims, assume all liability, and release, hold harmless, indemnify, ad agree to defend us (including our networked providers, agents, and employees) from liability for any injury, claim, cause of action suit, demand, and damages (Including, without limitation, personal bodily, or mental injury, property damage, economic loss, consequential damages, or punitive damages.) arising from or relating to (1) Failure to disclose any pre-existing condition, limitations, or sensitivities. ( 2.) Your failure to inform Roshelle K. LeVa L.Ac. (Shae LeVa) of pain, unsatisfactory treatment results, during or after any of your sessions at Northgate Center for Wellness or listed network affiliates. (3.) Your presence on the premises of Northgate Pain and Wellness location (4.) Any negligence on our part (including our networked affiliates.)

You agree that you understand the provisions contained with this agreement, and have had adequate time to review such provisions before signing, acknowledge and agree that your consent to these provisions is given in exchange for our rendering of services, and agree that these provisions apply at each session and/or class.

The listed people you permit to use this membership: For each individual, you sign for, if under 18, you agree to full responsibility for their conduct, and understand the same risks involved with treatment. If over 18 they must also sign this contract before receiving treatments.

You understand the arbitration agreement applies to all listed on the contract.

View the full arbitration agreement for hands-on acupuncture with description at http://www.acupuncturecouncil.com/AAC_PKG.PDF

Patient Signature_________________________________ Date:______________________________

Roshelle K. LeVa’s Signature_________________________________ Date: