Lockport Express Medical Group, Inc
16221 W 159 th Street Lockport, IL 60441
Fax : 815-838-4305 Phone 815-588-1111
Lockport Express Care Wellness Program
Membership Agreement
$ 200 [0-11 yrs] $ 220 [12-17 years] $ 240 [18-39 years]
$ 270 [40-64 years] $ 300 [65+ yrs]
I do hereby subscribe to membership in Lockport Express Care Wellness Program, as outlined below. During the membership period of twelve months, which starts today; I will be entitled to the following FREE benefits:
- Free Annual Physical Exam
- Free Blood Pressure measurements at any time
- Free Weight and Height Measurements at any time
- Free Annual Nutritional Assessment
- Free Annual Cardiovascular Risk Assessment
- Free Annual Vision Screening
- Free Lipid and Cholesterol Check once every five years for all adults
- Free Diabetes Screen once every three years for all patients 40 years or older
- Free Annual Colorectal Cancer Screen for all patients 50 years or older
- Free Gynecologic Assessment (PAP smear and HPV screen) once every two years for all females 20-30 years of age, and every three years for all females over 30 years of age
Additionally I will be entitled to the following discounted benefits, when clinically indicated:
- In-House evaluation for any medical complaint, by one of our healthcare providers, and with no required appointment, for only $ 15.00 per visit.
- In-House free treatment with Medications
- In-House Laboratory Testing for only $ 5.00 per test
- In-House Radiologic Exam for only $ 50.00 per exam
- In-House Intravenous Therapy for only $ 100.00 (initial) & $ 25.00 (additional or separate injections)
- In-House Influenza Vaccine (Flu Shot) at $ 11.40 (every fall) & Tetanus Booster (ADACEL) at $ 34.20
- In-House all Minor Surgical Procedures at a 70% discount off our standard prices
- In-House Orthopedic Supplies at discounted pricing
I hereby acknowledge that Lockport Express Medical Group does not treat life-threatening conditions. If it is determined that I have a life-threatening condition, I understand that I will be transferred to a nearby Emergency Room. I also acknowledge that Lockport Express Medical Group does not provide certain medical services, for which I might be referred to an outside source, and billed separately. Lockport Express Medical Group will not be held responsible for any of these services. These services include (but are not limited to) the following:-
Unusual medical conditions requiring referral to a specialist; Hospitalizations; Surgical Procedures requiring General or Regional Anesthesia; Blood transfusions; Mammography; Ultrasonography; CT Scanning; MR Imaging; Angiography; Pain Management; Prescribing Controlled Substances for any maintenance purposes; Prenatal Care; Laboratory Testing (other than tests provided at the Lockport Express Medical Clinic)
I hereby understand that my membership will be terminated at any time if payment is not made in full.
Patient / Guardian Signature : _________________________ Date : ___________________________
