Health Membership Plans No Insurance, No Problem Please select a plan below for a complete description. Sign the document before submitting. BASICBasic Monthly Membership Plan $25.00BASIC TERMS OF SERVICEThe BASIC PLAN is for people without health insurance or with a high-deductible health insurance plan. Individuals who require regular health screening exams or with occasional health problems should consider this plan. Monthly Fee = $25.00 (auto-renews)Per NP Visit = $75.00 Nurse Visit = $30.00 Telephone Consultation = $25.00 Telephone – Request Refill = $15.00 Early Termination Fee = $250.00 if plan is terminated before 1 year. Automatic renewal every month. *NOTE: If the member's debit or credit card fails to process the monthly payment, the membership is IMMEDIATELY TERMINATED, and the early termination fee is due. The expired member cannot receive medical care, nurse visits, telephone consults, or medication refills at Wilson's Health and Wellness Clinical Care. For questions, please call (770) 864-5538SILVERSilver Monthly Membership Plan $50.00SILVER TERMS OF SERVICEThe SILVER PLAN is for people without health insurance or with a high-deductible health insurance plan. Individuals who require regular health screening exams or with occasional health problems should consider this plan. Monthly Fee = $50.00 (auto-renews)Per NP Visit = $70.00 Nurse Visit = $25.00 Telephone Consultation = $20.00 Telephone – Request Refill = $10.00 Early Termination Fee = $250.00 if plan is terminated before 1 year. Automatic renewal every month. *NOTE: If the member's debit or credit card fails to process the monthly payment, the membership is IMMEDIATELY TERMINATED, and the early termination fee is due. The expired member cannot receive medical care, nurse visits, telephone consults, or medication refills at Wilson's Health and Wellness Clinical Care. For questions, please call (770) 864-5538 GOLDGold Monthly Membership Plan $75.00GOLD TERMS OF SERVICEThe GOLD PLAN is for people without health insurance or with a high-deductible health insurance plan. Individuals who have chronic medical problems like high blood pressure, diabetes, frequent headaches, asthma or frequent respiratory infections, recurring sinus infections, etc.... Monthly Fee = $75.00 (auto-renews)Per NP Visit = $65.00 Nurse Visit = $20.00 Telephone Consultation = $15.00 Telephone – Request Refill = $10.00 Early Termination Fee = $250.00 if plan is terminated before 1 year. Automatic renewal every month. *NOTE: If the member's debit or credit card fails to process the monthly payment, the membership is IMMEDIATELY TERMINATED, and the early termination fee is due. The expired member cannot receive medical care, nurse visits, telephone consults, or medication refills at Wilson's Health and Wellness Clinical Care. For questions, please call (770) 864-5538PLATINUMPlatinum Monthly Membership Plan $100.00PLATINUM TERMS OF SERVICEThe PLATINUM PLAN is for people without health insurance or with a high-deductible health insurance plan. Individuals who have significant, chronic medical problems like Rheumatoid Arthritis, Congestive Heart Failure, Stable Atrial Fibrillation, frequent headaches, moderate asthma, pneumonia, recurring bacterial sinus infections. Monthly Fee = $100.00 (auto-renews)Per NP Visit = $0.00 Nurse Visit = $0.00 Telephone Consultation = $0.00 Telephone – Request Refill = $0.00 Early Termination Fee = $250.00 if plan is terminated before 1 year. Automatic renewal every month. *NOTE: If the member's debit or credit card fails to process the monthly payment, the membership is IMMEDIATELY TERMINATED, and the early termination fee is due. The expired member cannot receive medical care, nurse visits, telephone consults, or medication refills at Wilson's Health and Wellness Clinical Care. For questions, please call (770) 864-5538Name *Email Address *Phone *Terms of Service *Terms of Service (TOS): By signing my name, I certify that I have read the TOS for my plan. Any questions concerning these policies have been discussed. My signature also certifies my understanding of an agreement with the above policies. I understand I am responsible for all charges if my debit or credit card fails to process monthly and or early termination fee applies. A photocopy or PDF of this document is as valid as the original. I may receive a copy of this document upon my request.Member's Signature *Start signing your signature hereYour browser does not support e-Signature field.Date *Submit