Spencer Health Network

Spencer Health Membership Order Form Individual Plans
Step 1 of 3: Determine your Charges.
Simply select your Card Type, Term and Start Date to calculate the cost of your order. If you have a promotion code, please enter in the “Promotion Code” box provided on the payment page. Your discount will calculate automatically. All memberships are one year policies with one annual payment.
Type of Card You are Ordering*
- Single ($45.00 annual payment + Applicable Taxes)
- Couple ($65.00 annual payment + Applicable Taxes)
- Family ($85.00 annual payment + Applicable Taxes)
Start Date*
MM slash DD slash YYYY

Step 2 of 3: Background Information
Name*
First Last
Additional Family Member Names:

*If you are adding multiple family members, please separate them by a comma.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Were You Referred?*
- Yes
- No
Referred By*
First Last
Referred By (Email)
Are you part of an organization?*
- Yes
- No
Organization Name:*
Contact Person at Organization:*
First Last
Contact Person Email
How did you hear about us?

Spencer Health Membership Order Form Individual Plans