Graduate Membership Application
Practice Phone #
Main Practice Information
Name of Practice
Practice Address (Street, City, State, Zip Code)
Best Time/Day to Call
# of Locations
# of Doctors
Membership Type: No contract or penalty clause. Please select from below.
Graduate Member Fee Schedule - First Year: $50/mo, Second Year: $100/mo and Third Year: $199/mo
Monthly ($199/mo. plus one-time application fee)
Annual (Save 10%)
Payment Information - Please call (855) 201-1639 if you have any questions
CVC Code (On back of card)
Name Exactly How it Appears on the Card
Billing Address (Street, City, State, Zip Code)
Digital Signature (Type Your Full Name)
By typing your name here you are authorizing OD Excellence to charge your card.
Terms of Membership
• Health Care Reform Program
• (8) Free Staff Pre-Employment Assessments
• Preferred Vendor Discounts, Rebates and Membership Offsets
• Online Message Board
• (8) ½ hour sessions of “One On One” Consulting with Experts
• Road to Success
• Practice Forms and White Papers
• Staff Education
• Medical and Practice Management Live Webinars – Can also be viewed in our archives and includes CE Credits
(Up to 24 webcasts per year plus past year archives with authorized CE available)
• Online Consumer Dr. Locator
• Monthly Membership Service Calls
• All Staff and Associate doctors are included
• And More……
Once you have submitted this application and the acceptance of the program will have processed your Application Fee (as defined below), your membership term will be on a monthly base. Your membership will renew automatically for successive months unless you notify us in writing of your intent not to renew your membership at least 7 days prior to the expiration of the month or any subsequent term. Member understands and agrees that information on buying patterns is made available to ODX which will help ODX to monitor vendor performance. Any information received will not be disclosed to any other party.
Your Application Fee for the Initial Term will be payable at sign up with the first months fee. Each month thereafter, the fee will be charged to the credit card on file. You have the option of cancelling your membership if you notify us in writing of your intention to do so. All the benefits of being a member in OD Excellence will cease immediately at that time.
You must notify us of your intention to cancel your membership. If you fail to cancel your membership, your credit card will be charged an additional amount equal to one (1) months installment within seven (7) days of the expiration of the month’s fee. Your membership will be renewed and your credit card charged unless you notify us in writing of your intention to cancel your membership at least seven (7) days prior to the expiration of any successive term.
We may terminate your membership at any time at our sole discretion. If terminated, you will be responsible for all fees up to that time. You will not be responsible for payment of any additional installments. All the benefits of being a member in OD Excellence will cease immediately at the time your membership is terminated, cancelled or expires. By completing and submitting this application to us, you are representing that all of the information contained in this application is true and correct and are authorizing us to charge your credit card as set forth in this paragraph.
You acknowledge that, as part of this application, you are providing us with certain information personal to you. We reserve the right to retain, license and use the personal information provided in conducting our business including, but not limited to, completing, shipping and tracking your orders; sending you information, offers or promotions; or contacting you for updated or corrected information in order to complete delivery of an order or to inform you of updates to content, products or services. In conducting our business, we may also analyze personal information on an individual or aggregate basis, in order to conduct statistical analysis of demographics of users, assess use of our products and services, and to amend existing and develop new content, services and products. We may share personal information with companies and individuals that perform functions on our behalf, or they may collect the personal information on our behalf and provide it to us. Examples include credit card processing, fulfilling subscriptions and other orders, delivering packages, sending postal mail and e-mail, data management, removing repetitive information from customer lists, etc.
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