Membership Agreement Who is your Physician?*Bart Price, MDPetra Travnicek, MD, FACPYour Name*DOB* MM slash DD slash YYYY Spouse (If Joining)DOB MM slash DD slash YYYY Children 1 (If Joining)DOB MM slash DD slash YYYY Children 2 (If Joining)DOB MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Spouse Work PhoneSpouse Cell PhoneSpouse Email Concierge Membership per member Price: $4,000.00 Quantity: Total $0.00 Payment Frequency Annually Semi-Annually QuarterlyPayment Method Electronic Debit from Checking or Savings (upload a voided check to our office) Mailing Check Mastercard/Visa American Express DiscoverUpload a copy of a VOIDED check Drop files here or Select filesAccepted file types: jpg, png, pdf, gif, Max. file size: 128 MB.Credit Card PaymentName on CardCard #Exp DateCVV CodeIs the Billing Address of your Card the same as your home address?*YesNoBilling address of credit card Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your SignatureReset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Spouse Signature (If Joining)Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
