AgelessCare | Health & Wellness for Any Age

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Membership SignUp
This Application is for the purpose of joining a discount medical plan

Membership Selection

Please select the discount medical plan you would like to subscribe to:

Platinum ($29.95/month)
Gold ($16.95/month)
Plus $20.00 One-time non-refundable processing fee

Review our Discount Medical Plans
Member privacy is our number one priority: Review our Privacy Policy.
Your Satisfaction Is Guaranteed.

Personal Information

Social Security#:

(numbers only, no dashes)

NOTE: Your Social Security# will NOT be used on your membership ID card. Having it helps us verify your identity with your medical providers.

*First Name:

*Last Name:

NOTE: Your first and last name will be printed on your membership ID card exactly as you enter it here.

*Address:

*City:

*State/Province:

*Postal Code:

*Country:

Please provide your contact phone number(s). Your phone number will be needed in the event of account notifications.

*Daytime Phone:

Evening Phone:

Other Phone:

*Your Gender:

*Birthdate:

(mm/dd/yyyy)

I would like to receive the AgelessCare News webzine.

Dependent Information

Spouse, children under the age of 25, parents age 60 and older, and any other IRS dependents may be included in your membership.

	First Name	Last Name	Relation	Birthdate	Gender
#1:
#2:
#3:
#4:
#5:
#6:

Your e-mail address will be used as your login ID. It will also be used by the system to send you receipts, and/or other correspondence.

*E-mail Address:

*Again:

Please specify a password between 6 and 16 characters in length.

*Password:

*Again:

Security Code

Security Code:
*Enter Above Security Code:

SignUp Information

*How did you hear about AgelessCare?

All New Members Must Read and Check Below:

I understand that the AgelessCare program is not an insurance program, and that I am responsible for paying the medical providers promptly for all services received when accessing AgelessCare networks. I also understand that neither AgelessCare nor the networks accessed are responsible for the outcome of the medical care received or the ultimate cost of that care. I also authorize AgelessCare to charge my credit or debit card for monthly membership fees according to the membership selected. By checking the box below, you indicate that you have read and understand the Member Terms and Conditions.
I have reviewed the Terms and Conditions and wish to purchase the discount medical plan.

Please check your information for accuracy. Then, proceed to the next step by clicking the Continue button below.

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