Lifestyle Membership Registration

All membership information and questionaire components must be completed and payment tendered. Once your payment information has been approved, you will receive an itemized invoice for your records. If your insurance company or employer covers these services, you can use this invoice to seek reimbursement. ANWAN Wellness does not accept insurance nor do we bill insurance companies for services.

Note: Information marked with an asterisk (*) is required.

Personal Information

First Name*

Last Name*

Age*

Date of Birth*


(e.g 1956)

Street Address*

Apt. or Suite # (Optional)

City*

State*		Zip Code*		Country
				USA

Primary Phone*

- -

Extension

( )

Alternate Phone (Optional)

- -

Extension

( )

E-mail Address*

Please select if the address is residence or business. (Optional)
Residence
Business Name

Lifestyle Membership Preference

Sign me up for 1 year at $49.95 per year

Sign me up for 3 years at $129.95 (save $20.00)

Sign me up for 5 years at $195.00 (save $54.75)

User Name and Password

Please create a user name at least three characters long and a password at least six characters long. You can use any combination of numbers and letters. Password is case sensitive.

If you are having trouble creating a unique user name, we suggest using your e-mail address.

User Name*		Password*		Password Verify*

Yes! I'd like to periodically receive information about new features, products, and special offers via email.