Membership Sign Up

Dr Dale’s Membership Signup

 

This membership is a 3 month agreement, $20 per month, billed quarterly.
Therefore, please fill out the following form and check the box at the bottom of the form that you agree to all membership terms including three months of membership. There are no cancellations during the three months.
Your Account Information
E-mail Address:
Confirm E-mail Address:
Password:
Re-enter Password:
Your Mailing Address
First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State/Province/Region:
Zip/Postal Code:
Country:
Phone Number:
Your Billing Address
Same as above
Address Line 1:
Address Line 2:
City:
State/Province/Region:
Zip/Postal Code:
Country:
I have read and agree to the Terms of Use
After paying for membership at PayPal, you must follow the link back to the Wellness Center website so that your payment is confirmed in our database.

Only after paying and then confirming will you be able to login as a member.

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