Enrollment Form

Name*
First Last
Phone*
Email*
Program*
- ND1 - New Direction 1
- ND2 - New Direction 2
- LCP (self-pay)
- VLCP (self-pay)
Program Terms & Conditions*
I understand that by submitting this form I am in effect signing and agreeing to all terms listed below
• I realize that I have the option of leaving the program at any time but I must notify the center in writing 14 days prior.
• I understand that I will be added to the Physician's Choice Wellness (PCW) Email List in order to be emailed information pertaining to my program participation as well as any special notices from PCW. PCW does not share email or personal information with third parties.
• I understand that there will be no refund given for missing a class/clinic.
• I understand that by submitting this form I am in effect signing and agreeing to all terms listed above.
PCW Monthly Fee for ND1 or ND2 or LCP or VLCP Program*
Price:
Your credit card will be charged automatically each month for your ND1 or ND2 or LCP or VLCP Program. You may cancel anytime with 14 days' advance notice.
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa