Account Change Request - Lifequest Fitness

Client Account Management Request Form

Use this form to request changes to your current Wellness Plan account.

Please submit requests at least 5 business days before your billing cycle. Requests received after that time may be applied to the following billing cycle. Applicable prorated charges and current Wellness Plan rates may apply.

Client Account Management Request Form

Account Holder's Full Name

Date of Birth

Email Address

Phone Number

Street Address

City, State, and Zip Code

How can we help you today?

Change people on my Wellness Plan

Change my payment date

Place my Wellness Plan on hold

Restore/Reactivate my Wellness Plan

Add locker rental service

Cancel locker rental service

Cancel my Wellness Plan

Change people on my Wellness Plan

Add / Remove People From My Wellness Plan Input

What is your CURRENT Wellness Plan?

Individual

Couple

Family

Family Plus

Senior Individual

Senior Couple

I'm not sure

Please enter each person you would like to add or remove.

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

What would you like to do?

ADD this person

REMOVE this person

Full Name

Date of Birth

Is this person's contact information the same as the Account Holder's?

Yes

Contact Information

Email Address

Phone Number

Street Address

City, State, and Zip Code

Do you need to add or remove another person to your account?

Yes

Making Changes for More Than Seven Clients?

No problem! Please continue and submit your request. A member of our team will contact you to gather the additional information needed.

Additional Account Changes

I have additional client changes and would like a team member to contact me to complete my request.

Total People AFTER Requested Changes

Please provide the total number of clients who will be on your Wellness Plan after all requested changes are completed.

After these changes are completed, how many TOTAL clients will be on your Wellness Plan?

8 or more

Updated Wellness Plan

Our team will determine the appropriate Wellness Plan and current rate based on the clients remaining on your account.

Your new rate will take effect when the account change is processed. Depending on the effective date, a prorated charge may apply.

If your account contains more than seven clients, we will contact you regarding your updated pricing.

Current rates are as follows:

Individual (1 client) — $64.25/month
Couple (2 clients) — $103.46/month
Family (3–4 clients) — $158.99/month
Family Plus (5–7 clients) — $191.66/month
Senior Individual (age 65+, 1 client) — $58.81/month
Senior Couple (age 65+, 2 clients) — $91.48/month

Rates shown include applicable tax.

Account Change Fee

A $20 Account Change Fee applies to this request.

How would you like to pay the Account Change Fee?

Charge the payment card currently associated with my account

I prefer to pay the fee in person

Place My Wellness Plan on Hold

Wellness Plans may be placed on hold for up to three months per calendar year for $10.00 per month. The hold fee may be waived for qualifying medical reasons when appropriate documentation is provided.

Your account must be current, and requests should be submitted at least 5 business days before your billing cycle.

Requested Hold Start Date

Requested Hold End Date

Reason for Hold

Medical

Travel

Financial

Temporary Relocation

Personal

Other

If you answered medical above:

A member of our team may contact you for additional information or documentation from your medical provider. Submission of this request does not guarantee waiver of the application hold fee.

Restore / Reactivate My Wellness Plan

What would you like to reactivate?

A Wellness Plan cancellation

A Wellness Plan hold

Requested reactivation / restoration date

Reactivating your account reverses your previous cancellation or hold request. Applicable Wellness Plan dues and other reocurring account charges will resume.

Authorization

I authorize the reactivation of my Wellness Plan and the resumption of applicable recurring charges.

Add Locker Rental

Who is the locker rental for?

What size locker you prefer?

Small locker - $6/month

Large locker - $10/month

Locker service requires a minimum commitment of three consecutive months and will continue month-to-month afterward until cancelled.

Monthly locker charges will be processed with your Wellness Plan payment using the payment method on file.

Locker service is a "use it or lose it" service. Refunds or credits are not provided for unused periods.

Locker Service Authorizaton

I have read and agree to the Locker Service terms above.

Cancel Locker Rental

Locker Number

Locker Location

Women's Locker Room

Women's Pool Locker Room

Men's Locker Room

Men's Pool Locker Room

Requested Cancellation Date

Please remove all belongings from your locker on or before the effective end date. Allow up to 5 business days for processing. You will receive confirmation when your locker service has been cancelled.

Locker Cancellation Authorization

I understand the terms above and authorize cancellation of my locker service.

Cancel My Wellness Plan

What is the primary reason you are cancelling?

Moving / Relocating

Financial Reasons

Medical / Health Records

Not using my Wellness Plan enough

Schedule / Time contraints

Facility or service concerns

Switching to another facility

Other

To the best of your knowledge, have you completed your initial 4-month agreement obligation?

Yes

I'm not sure

Cancellation Terms

Your Wellness Plan requires 30 days’ notice for cancellation. You remain financially responsible for all applicable dues and charges during the 30-day notice period and may continue using the facility through your effective cancellation date.

If you have not completed your initial 4-month agreement obligation, a $99 early cancellation fee will be charged when your cancellation is processed. Our team will verify your agreement dates to determine whether the fee is due.

Once your request has been processed, you will receive a confirmation email with your effective cancellation date, final payment information, and any applicable early cancellation fee.

Cancellation Authorization

I understand the cancellation terms above and authorize The Wellness Clinic at LifeQuest to process my Wellness Plan cancellation request.

Change My Scheduled Dues Payment Date

Need a different payment date?

We're happy to help! Use this section to request a change to the date your recurring Wellness Plan dues are processed.

Requested NEW Payment Date

When would you like this change to begin?

Payment Date Change

Please submit your request at least 5 business days before your currently scheduled payment date. Requests received after this timeframe may not take effect until the following billing cycle.

Changing your scheduled payment date may result in a prorated charge or adjustment when the change is processed. Our team will review your account and confirm your new payment date and any applicable adjustment.

Authorization

I authorize The Wellness Clinic at LifeQuest to change my scheduled Wellness Plan payment date and understand that applicable prorated charges or adjustments may apply.

Review & Authorization

Ready to submit your request?
Please review your responses for accuracy before submitting.

Submitting this form does not mean your requested change has already been processed. Our team will review your request, verify your account information and applicable terms, pricing, fees and effective dates, and contact you if additional information is needed.

You will receive an email confirmation once your request has been processed.

Account Holder's Legal Name

Authorization

I certify that I am the account holder or an authorized person on this account. I authorize The Wellness Clinic at LifeQuest to process the request submitted above and understand that applicable notice periods, fees, prorated charges, current Wellness Plan rates, and other terms of my agreement may apply.

Client Account Management Request Form

Change people on my Wellness Plan

Please enter each person you would like to add or remove.

Contact Information

Contact Information

Contact Information

Contact Information

Contact Information

Contact Information

Contact Information

Making Changes for More Than Seven Clients?

Total People AFTER Requested Changes

Updated Wellness Plan

Account Change Fee

Place My Wellness Plan on Hold

Restore / Reactivate My Wellness Plan

Add Locker Rental

Cancel Locker Rental

Cancel My Wellness Plan

Cancellation Terms

Change My Scheduled Dues Payment Date

Payment Date Change

Review & Authorization

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