Name* First Last Phone*Email* Office Name*Website Office Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code License Number*Personal injury billingCheck all that apply Attorneys Lien Medical Lien Third Party Pip Med Pay Other Speciality* Chiropractor Physical Therapist Medical Doctor Orthopedic Doctor Neurologist Pain Management Additional CommentsTerms and ConditionsACCIDENTDOCTOR.ORG https.accidentdoctor.org Healthcare Provider – Terms of Membership Updated: August 27th 2019 Please read the following Healthcare Provider Terms of Membership (this “Agreement” OR “ToM”) carefully before registering as a Healthcare Provider on ACCIDENTDOCTOR.ORG WEBSITE. By clicking on the “SUBMIT” button where such action is identified as having the effect of accepting these Terms and Conditions. You acknowledge, represent and warrant that you are a licensed medical provider and authorized to accept these Terms and Conditions. Your Acceptance of these Terms and Conditions has the effect of making the member a party and bound to these Terms and Conditions. The information submitted by you to Accident Doctor.org, via online forms or otherwise, is authentic and correct. Pursuant to these Terms and Conditions, Advertiser submits business listing(s) for, and/or link(s) to, its web site(s) for inclusion on accidentdoctor.org website, personal-injury-doctor.com website if applicable. As a healthcare provider you are subject to ethical and professional rules and regulations as set by your state of licensure. Please verify all applicable, advertising rules before signing up as a member as defined below. Except as you may specifically advise any patient, no doctor-patient privilege shall exist with respect to any communication with or through the website ort the provision of its memberships. All fees, including any membership, advertising, promotion or placement fees are explained during the registration or order process and are subject to change from time to time at our absolute and sole discretion. By entering into this agreement, you acknowledge that fees may have an initial and recurring payment feature and you accept responsibility for all reoccurring charges prior to cancellation. By registering on the website or subscribing to our membership, you agree to receive free content and or promotional offers from us. Our business changes constantly, as do our policies, rules and regulations posted on the website or this agreement. It is your expressed obligation to check the website frequently to see if there are any recent changes to this agreement. We reserve the right to revise this agreement at any time without providing notice. Your continued use of the website, the membership or your account shall be deemed an irrevocable acceptance of any such revisions. Your access to the website and the usage of any membership is void and unauthorized where prohibited by applicable law or regulation. Description of the WEBSITE: The WEBSITE provides Healthcare Providers (“you” or “Doctor”) with a resource and tool designed to enhance patient (“Patient”) access and retention through advanced communication and online capabilities. All activities and capabilities offered by or through the WEBSITE, including all advertisings, promotions, placements and communications shall individually and collectively be referred to as “Memberships”. ADG LLC reserves the right to add, change, modify, suspend or discontinue any portion of the WEBSITE or the Membership(s) offered at any time. ADG LLC may also impose limits on certain Memberships or features and/or restrict Healthcare Provider or Patient access to the WEBSITE or any Memberships in our sole and absolute discretion and without notice or liability to anyone. Healthcare Providers: The term “Healthcare Provider(s)” shall be exclusive to medical professionals currently licensed to in their U.S. State of licensure. Eligibility: All Healthcare Providers must be eighteen (18) years of age or older to enter into this Agreement. This WEBSITE and its Memberships were designed for Healthcare Providers who are licensed in and are legal residents of the United States and its territories. S. licensed Healthcare Providers residing in other countries are advised not to disclose personal information unless they consent to having their information used as set forth in this WEBSITE’s Privacy Policy rather than under the law of their home country. Usage of the WEBSITE and Memberships is void where prohibited. Professional Responsibility: As a Healthcare Providers you are subject to ethical and professional standards, laws, rules and regulations as set by your state of licensure. It is your responsibility to verify that any and all Memberships you subscribe to or actions you engage on or through the WEBSITE and its Memberships are in full compliance with applicable standards, laws, rules and regulations. ADLLC assumes no responsibility and shall have no liability whatsoever for your use of, or inability to use, the WEBSITE or Memberships. Doctor-Patient Privilege: Except as you may specifically advise any Patient, no Doctor-Patient privilege shall exist with respect to any communication with or through the WEBSITE or the provision of its Memberships. The WEBSITE provides various Memberships that enable direct communications, whether private or public, between Healthcare Providers and Patients. Please make sure to assess each Membership’s compliance with applicable state’s laws and regulations. It is your responsibility to properly advise any Patient, both prospective and existing, of the status of any Doctor-Patient privilege with respect to communication using the Memberships. If you have any questions with respect to the technical aspects of any form of communication provided through our Memberships, please contact us at SUPPORT@ACCIDENTDOCTOR.ORG. ADLLC assumes no responsibility and shall have no liability whatsoever for your use of the WEBSITE or Memberships in any manner not in compliance with applicable Doctor-Patient standards, laws, rules and regulations. Memberships: The WEBSITE offers registered Healthcare Providers both free and paid Memberships (“Premium”). The WEBSITE from time to time may post additional and new Premium Memberships that may require additional fees (“Fees”). Any and all Premium Memberships shall require the registration of an Account through which Healthcare Providers may promote their Memberships as well as manage Patient Membership term Our Premium Memberships are made available to you subject to a minimum one-year term. The above notwithstanding, ADG LLC may provide you with various payment options including a one time annual payment as well as periodic (e.g. quarterly) subscriptions. Regardless of the payment option offered or chosen, your payment obligations shall remain for the full one-year minimum term of the Premium Memberships. The WEBSITE’s Fees and any terms for Premium Memberships, including any available discounts, are explained to Healthcare Providers during either the registration or Membership order process and are subject to change from time to time at ADG LLC’s absolute and sole discretion. Please note that any Fees that are disclosed to you in the registration or Membership order process are deemed part of this Agreement. You agree to pay ADLLC for all usage and/or subscription Fees charged to your Account, as per this Agreement. All charges will appear on your credit card bill. In the event that you signed up, first accessed or created an Account on the WEBSITE subject to or in accordance with any free, limited or other trial subscription period, please be aware that after that trial period expires, we will begin to bill your credit card account on a periodic schedule for the Memberships, unless you terminate your Account prior to the end of the trial or free period. Please verify all terms associated with such promotion to verify your obligations. You can always cancel your Account by following instructions on the WEBSITE, Memberships or by sending an e-mail to SUPPORT@ACCIDENTDOCTOR.ORG. Failure to Pay: If for any reason ADG LLC is unable to charge your credit card for the amount owed for the Premium Memberships provided, or if ADG LLC receives notification of a chargeback, reversal, payment dispute, or is charged a penalty (together “Penalty”) for any fee it previously charged to your credit card, you agree that ADG LLC may pursue all available lawful remedies in order to obtain payment, including but not limited to, immediate cancellation, without notice to you, of any Premium Memberships provided. ADG LLC also reserves the right to charge you reasonable “processing fees” for any Penalty incurred by ADG LLC as a result of your noncompliance with this Agreement (as determined by ADG LLC in its sole and absolute discretion). These processing fees will be billed to the credit card you have on file with ADG LLC. Except as otherwise described as a minimum term for a Premium Membership during the Registration or order process, you may terminate your Account or Membership at any time. The above notwithstanding, Premium Memberships subject to a minimum one-year term may be terminated with a 30-day notice, subsequent to the end of an initial 90 day paid subscription. Such notice will not affect charges submitted before ADG LLC could reasonably take action in response to your notice. Such notice shall also not be effective if any fees or moneys are due and unpaid by Member prior to receipt of such notice by ADG LLC. Further, no refund or chargeback shall be permitted for either the initial 90-day paid subscription or for any 30-day notice period. Your non-termination or continued use of the Premium Memberships reaffirms that ADG LLC is authorized to charge your account. ADG LLC may submit those charges for payment and you will be responsible for such charges. Your charges may be payable in advance, in arrears, per usage, or as otherwise described when you initially registered your Account or subscribed to the Premium Memberships. Credit Policy: Except for Premium Memberships provided subject to a minimum term, upon termination, you will no longer be invoiced for future Premium Memberships not owed. ADG LLC, HOWEVER, WILL NOT REFUND ANY PREMIUM MEMBERSHIP FEES PAID OR OWED BY YOU FOR ANY REASON WHATSOEVER, IN WHOLE OR IN PART. Any changes are effective upon Notice to You. Notice may be provided to you by delivering such changes via electronic mail, TXT/SMS messages or any other means that we deem reasonable, in our sole and absolute discretion (“Notice”). Registration: In order to subscribe to our Premium Memberships, you will be required to create an Account. You may never use someone else’s Account. You may also never grant anyone else access to your Account. When creating an Account on the WEBSITE or Memberships, you agree to provide accurate, current and complete information about yourself (“Registration Data”) as prompted by our registration form. Registration Data may include your personal name, company name, e-mail address, password, billing address and credit card information. Registration Data may also include voluntary relevant information such as areas of practice, license information, and size of practice. Editorial Standards Advertiser listings are written by accident doctor, listings are stored in database, and are listed as follows: Name of Business Address City State Zip Code Phone Numbers Website You also represent that we may rely on your Registration Data as accurate, current and complete. You agree to maintain and update your Registration Data to keep it accurate, current and complete. We reserve the right, in our sole and absolute discretion, to terminate your Account for inaccurate, untrue, deceptive and/or incomplete Registration Data. Landing pages We can create landing pages for you in your particular city or market under a paid listing. However, we do not provide the content for such pages. If you wish to have a landing page, please write a minimum of 300 unique word documents describing your business, Memberships, etc. When you are done, please send it to renee@accidentdoctor.org. The content that you write will be the property of accident doctor group. We will not change anything that you write after it is sent in and published. We will do minor content changes such as change in phone number, address, or url. We reserve the right not to publish any landing page we deem not to comply with our standard SEO practices. ( Duplicate content, repetitive content, keyword stuffing ) Term/Termination: We may decide at any time in our sole and absolute discretion whether to remove and/or terminate your access to the WEBSITE or our Memberships, for any reason, including but not limited to violations of this Agreement. We may or may not provide notice to you of such termination through any reasonable means including, but not limited to, sending notice to you at the e-mail address that you provided during or subsequent to registration or purchase. Such termination is effective when executed by us or upon transmittal by us. However, your obligations of indemnification pursuant to this Agreement shall survive the termination of your Account or this Agreement. Withdrawal of consent or request to have your Account terminated will have no effect on the legal validity and/or enforceability of this Agreement for the time period prior to your request and during the time period needed for us to reasonably act to comply with your request. Indemnification: You agree to indemnify, defend and hold us, and our subsidiaries, affiliates, officers, parent companies, agents, co-branders or other partners, and employees (each a “Covered Party”), harmless, at your expense, against any and all claims, actions, proceedings, and suits and all related liabilities, damages, settlements, penalties, fines, costs and expenses (including, without limitation, reasonable attorneys’ fees and other dispute resolution expenses) incurred by any Covered Party or other third party and arising out of, (i) your use or misuse of the WEBSITE or the Memberships, (ii) arising from your breach of this Agreement, or (iii) arising from your violation or breach of any term of this Agreement or other policies, rules or guidelines referenced herein. Warranties: You expressly agree that access and/or use of the WEBSITE and/or Memberships is at your sole risk. The WEBSITE and Memberships are provided on an “AS IS” and “AS AVAILABLE” basis, without any express or implied warranty of any kind, including, but not limited, non-infringement of intellectual property. The WEBSITE and/or Memberships may contain bugs, errors, problems or other limitations. We and the Covered Parties have no liability whatsoever for your use of, or inability to use, the WEBSITE and/or Memberships to the fullest extent permitted by applicable law. We and the Covered Parties are not liable to you or to any third party for any indirect, special, incidental or consequential damages, whether based on breach of contract, breach of warranty, tort (including negligence), product liability or otherwise, even if advised of the possibility of such damages. The negation of damages set forth above is a fundamental element of the basis of the bargain between us and you. The WEBSITE and Memberships would not be provided to you without such limitations. No advice or information, whether oral or written, obtained by you from us through the WEBSITE and/or Memberships shall create any warranty, representation or guarantee not expressly stated in this Agreement. We are not responsible to you and/or any third party, without limitation, for: 1) any error, omission, interruption, deletion, defect, delay in operation or transmission, communications line failure, theft or destruction or unauthorized access to or alteration of, communications; 2) the conduct of any person, whether online or offline; 3) any computer virus or other malicious, destructive or corrupting code, agent, program or macros; 4) any infringement of another’s rights, including intellectual property rights; or 5) any violation, intended or otherwise, of applicable state or professional laws, rules or regulations. You agree that ADLLC is not the publisher of any Submissions, as define above, found on the WEBSITE and, as such, shall not be liable for damages arising there from including, without limitation, any and all criminal and/or civil liability. ADLLC shall not be liable to you for any Memberships, goods and/or information available from third parties, even if obtained at or through the WEBSITE and/or Memberships. If you are dissatisfied with the WEBSITE and/or Memberships or with this Agreement, your sole and exclusive remedy is the cancellation of your Account and to discontinue use of the WEBSITE and Memberships (subject to any termination restrictions). Miscellaneous: Should any part of this Agreement be held invalid or unenforceable, that portion shall be construed consistent with applicable law and the remaining portions shall remain in full force and effect. To the extent that anything in or associated with, the WEBSITE or Memberships is in conflict or inconsistent with this Agreement, this Agreement shall take precedence. Our failure to enforce any provision of this Agreement shall not be deemed a waiver of such provision nor of the right to enforce such provision, or any other provisions in this Agreement. You expressly authorize us to comply with any and all lawful notices, subpoenas, court orders and/or warrants without prior notice to you. Dispute Resolution: If a dispute arises between you and us, our goal is to provide you with a neutral and cost effective means of resolving the dispute quickly. Accordingly, you agree that we will resolve any claim or controversy at law or equity that arises out of this Agreement, the WEBSITE or our Memberships (a “Claim”) in accordance with one of the subsections below or as we and you otherwise agree in writing. Before resorting to these alternatives, we strongly encourage you to first contact us directly to seek a resolution by sending an email to SUPPORT@ACCIDENTDOCTOR.ORG. We will consider reasonable requests to resolve the dispute through alternative dispute resolution procedures, such as mediation or arbitration, as alternatives to litigation. License Advertiser hereby grants to the accident doctor group a worldwide, limited, non-exclusive, non-transferable, royalty-free license to reproduce, distribute, transmit, display, perform, download, cache, store on its servers, and otherwise use Advertiser’s listings and submissions, and any portion thereof, including, without limitation, Advertiser’s trademarks, trade names, Membership marks and logos set forth therein, or as otherwise specified in writing by Advertiser (collectively the “Advertiser Marks”), solely to display and provide Advertiser’s listings and links in accordance with these Terms and Conditions. Email Under the Free Doctor listing, Doctors will get an email from us no more than once a week. This email will contain information regarding vendors the accident doctor group has relationships with. If the Doctor or advertiser does not wish to receive, blocks, any emails from the accident doctor group, or reports the Accident Doctor Group as “spammers”, his or her listing could be removed without further notification. Choice of Law and Forum Accident Doctor Group reserves the right, in its sole discretion, to (i) remove Advertiser’s Listings and/or cancel Advertiser’s account for any reason. Violation of any other term or condition of these Terms and Conditions, including, without limitation, repeated infringement of third party copyrights. These Terms and Conditions: (a) shall be governed by and construed in accordance with, the laws of the State of Georgia, without giving effect to principles of conflicts of law; (b) constitutes the complete and entire expression of the agreement between the parties with respect to the subject matter hereof; and (c) shall supersede any and all other agreements, whether written or oral, between the parties, including, without limitation, any print, online and electronic promotional materials. All waivers hereunder by accident doctor must be expressly made in writing. Should any provision of this contract be held to be void, invalid, or inoperative, such provision shall be modified to reflect the fullest enforceable intent of the parties, or if such modification is not possible, severed, and the remaining provisions of this contract shall not be affected and shall continue in full force and effect. Exclusive venue for all disputes arising out of or related to these Terms and Conditions shall be the state and federal courts located in Cobb County, Georgia, and each party hereby irrevocably consents thereto. Any rights or obligations hereunder may not be transferred or assigned by Advertiser without the prior written consent of accident doctor. Accident Doctor may freely assign and delegate the Agreement and any of its rights and obligations hereunder. Limitation of Liability IN NO EVENT SHALL ACCIDENT DOCTOR .ORG OR ANY OF ITS SUPPLIERS, VENDORS OR AFFILIATES BE LIABLE OR RESPONSIBLE FOR ANY INDIRECT, INCIDENTAL, CONSEQUENTIAL, SPECIAL OR EXEMPLARY DAMAGES OF ANY KIND, INCLUDING WITHOUT LIMITATION, LOST PROFITS OR LOST OPPORTUNITIES, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES IN ADVANCE AND REGARDLESS OF THE CAUSE OF ACTION UPON WHICH ANY SUCH CLAIM IS BASED. Legal Warning: Any attempt by any individual, whether a Healthcare Provider, Patient or otherwise to damage, destroy, tamper with, vandalize and/or otherwise interfere with the operation of the WEBSITE and/or Memberships, is a violation of criminal and civil law and we will diligently pursue all remedies in this regard against any offending individual or entity to the fullest extent permissible by law and in equity. This document constitutes a binding agreement. By checking “I accept these Terms and Conditions,” on the Member Registration Page, you agree that you have had the opportunity to read this Agreement and agree to each and all of the provisions and conditions therein. Further, you understand that you are signing a non-refundable binding agreement. Membership terms and conditions page Contact Us: Accident Doctor Group 2146 Roswell Road, Suite 629 Marietta, GA 30060 SUPPORT@ACCIDENTDOCTOR.ORG I agree with the terms and conditions* Yes What Type of Service would like?*Silver $100.00/moGold $250.00/moPlatinum $500.00/mo