INDIVIDUAL: $95 per month + applicable taxes
FAMILY: $145 per month + applicable taxes
Membership Coverage* :
IndividualFamily
Referred By :
Personal Information:
Full Name (FIRST/LAST) *
Date of Birth (YYYY-MM-DD) * Gender * MaleFemaleOtherRather not say
Preferred Email * Preferred Phone *
Home Address (NUMBER/STREET)*
City * Province * OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukon Postal Code *
Company Information:
Name of Company*
Company Address
City Province OntarioAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutPrince Edward IslandQuebecSaskatchewanYukon Postal Code
Spouse/Partner (Family plan only):
Date of Birth (YYYY-MM-DD) Gender MaleFemaleOtherRather not say
Preferred Email * Preferred Phone
Dependents (Family plan only):
Do you have any dependents?: YesNo
* max four, up to age 25
Full Name (FIRST/LAST) Date of Birth (YYYY-MM-DD) Gender MaleFemaleOtherRather not say Preferred Email(Required for ages 18 and over)
Full Name Date of Birth Gender MaleFemaleOtherRather not say Preferred Email
Billing frequency* :
MonthlyAnnual
Please note that in order to protect your financial information, we will send you a secure link to collect your credit card details and activate your membership.
Mailing Preferences
Welcome Package: DigitalMailed
Book by Kevin Brady - Never too late to be healthy: DigitalMailed
Membership Terms and Conditions:
For the full terms and conditions, please click here
I have read the above and agree to all terms and conditions
Signature (please type your full name) * Date (YYYY-MM-DD) *
Advica Health™, a division of Royal VIP Health Options Inc.
QUESTIONS? CONCERNS? Please email Advica Health at [email protected]Note: This application form and pricing replaces any previous Advica or VIP Health Options Inc. application forms.