Regen Plan Enrollment Please enable JavaScript in your browser to complete this form.In which market are you enrolling? *BrentwoodMurfreesboroName *FirstLastEmail *Phone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRegen Plan Monthly Recurring Membership *Price: $ 300.00I agree to annual enrollment with IMAC Regeneration Center for care described above. I acknowledge and understand that my agreement to the fees listed is based on annual assessment of pricing. My annual fee is non-refundable and is not dependent on cancellation of any or all services. Annual Membership Fee will be due at time of initial examination. I understand that the Regen Plan requires twelve (12) monthly payments and is non-refundable and cannot be cancelled at any time for any reason. If I receive services under this plan, I understand that failure to pay the monthly fee may impact my credit rating with TransUnion, Equifax, Experian, and/or any other credit rating bureau. This agreement is not an extension of credit based on credit worthiness nor is it a gurantee of results.CardName on CardEmailSign Me Up! Committed to People, Committed to your Future. BOOK APPOINTMENT