Elon Wellness — Provider Delivery Questionnaire

Based on the Corporate Wellness Event Agreement | Complete one form per provider. Answer each question as accurately as possible.

Step 1 of 8 - Array

12%

PROVIDER INFORMATION

Provider / Clinic Name(Required)

Provider Contact Name(Required)

State / Location

Date Agreement Signed with Elon Wellness

MM slash DD slash YYYY

Total Amount Paid to Elon Wellness (or financed through Affirm)

Date This Questionnaire Was Completed

MM slash DD slash YYYY

SECTION A — ONBOARDING & LAUNCH PROCESS

Contract Sections 2.1, 6

A1 | Contract Ref: Section 6
Elon's Promise: After signing, an Elon Wellness representative would schedule an onboarding call.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

A2 | Contract Ref: Section 6
Elon's Promise: During the onboarding call, Elon would collect all necessary information to develop your campaign.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

A3 | Contract Ref: Sections 2.1 & 6
Elon's Promise: The first Event would be scheduled within 20–30 business days following the onboarding call.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

A4 | Contract Ref: Section 6
Elon's Promise: Campaign launch would follow promptly after the onboarding call.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

SECTION B — CONTRACTED DELIVERABLES

Contract Sections 3, 5

B1 | Contract Ref: Section 3
Elon's Promise: Elon would conduct local marketing research to identify target companies in your area.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B2 | Contract Ref: Sections 3 & 5
Elon's Promise: Elon would analyze corporate healthcare spend, including pharmaceutical expenditures.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B3 | Contract Ref: Sections 3 & 5
Elon's Promise: Elon would create a customized signature talk and irresistible offer aligned with your brand and services.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B4 | Contract Ref: Sections 3 & 5
Elon's Promise: Elon would build all presentation and marketing materials, including slide decks and visual assets.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B5 | Contract Ref: Section 3
Elon's Promise: Elon would coordinate directly with HR departments at host companies.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B6 | Contract Ref: Section 3
Elon's Promise: Elon would promote Events and manage all logistics.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B7 | Contract Ref: Section 3
Elon's Promise: Elon would offer a virtual presenter if you chose not to present yourself.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B8 | Contract Ref: Section 3
Elon's Promise: Elon would support onboarding and new patient flow based on your preferences.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

B9 | PROOF OF HR CONTACT & PRESENTATIONS (Legally Significant)

⚠ IMPORTANT: This question is critically important. One of Elon Wellness's core contractual promises was to actively contact HR departments and companies in your local area to schedule events. Please answer as specifically as possible.

B9: Did Elon Wellness ever provide you with proof that they contacted HR departments or companies in your area as promised?(Required)

Yes

Partial

If YES — What proof was provided? (Select all that apply)

Names of specific companies contacted

Contact logs or call records

Email correspondence with HR departments

Presentation logs or meeting notes

Written confirmation from any HR department

Other (describe below)

Please describe in detail any proof of HR contact or presentations Elon Wellness provided (include dates, company names, and documentation received). If none, type: 'No proof of HR contact or presentations was ever provided to me.'

Did Elon Wellness ever verbally claim to have contacted HR departments without providing written proof? If so, describe what was said and when:

SECTION C — EVENT DELIVERY & ATTENDANCE

Contract Sections 2.2, 2.3

C1 | Contract Ref: Section 2.2
Elon's Promise: You were entitled to one (1) Event per calendar month, up to 12 Events total.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

C2 | Contract Ref: Section 2.3
Elon's Promise: Elon guaranteed a minimum of 35 employee attendees per Event.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

C3 | Contract Ref: Section 2.3
Elon's Promise: If fewer than 35 attended, Elon would schedule a replacement Event within 30 days.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

How many total Events were actually delivered? (Write a number):

List the dates of any Events that were promised but never delivered:

SECTION D — FINANCIAL PROMISES & REFUNDS

Contract Sections 7.2, 8.2, 8.4, 9

D1 | Contract Ref: Section 7.2
Elon's Promise: Elon would reimburse $2,000 (covering the first two Events) BEFORE your first Affirm payment was due.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

D2 | Contract Ref: Section 8.2
Elon's Promise: If terminated early, Elon would refund unused Events within 14 days (Unused Events x $1,000).

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

D3 | Contract Ref: Section 8.4
Elon's Promise: If Elon materially failed to deliver, they would reimburse any finance-related interest on unused Events.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

D4 | Contract Ref: Section 9
Elon's Promise: Elon guaranteed a positive ROI — at least one attendee enrolling and paying within 30 days of each Event. If not, a $1,000 refund within 14 days.

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

D5 | REFUND SOURCE & PAYMENT METHOD (Legally Significant)

⚠ IMPORTANT: It is critically important to identify WHERE any refund came from — specifically whether it was sent from an official Elon Wellness corporate account or from a personal account (e.g., personal Zelle, PayPal, Venmo). This distinction is highly relevant to fraud complaints filed with the AG, CFPB, and in civil court proceedings.

D5: Did you receive any refund or partial payment from Elon Wellness at any point?(Required)

Yes

If YES — What was the total amount refunded or paid to you? (e.g., $500.00)

If YES — What payment method was used? (e.g., Zelle, Venmo, PayPal, personal check, business check, bank wire, cash, other)

CRITICAL: Record the exact name/account as it appeared on the transaction (e.g., 'Zelle from Kevin Hufford' or 'Elon Wellness LLC'):

Upload documentation of this transaction (screenshots, bank statements, email confirmations, receipts):

Accepted: jpg, jpeg, png, pdf, doc, docx

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 5 MB, Max. files: 10.

What date(s) was the refund or payment received?

Did the refund cover the FULL amount owed to you, or only a PARTIAL amount? Please explain:

SECTION E — COMMUNICATIONS & DEFERRALS

E1 | Contract Ref: General
Elon's Promise: Did Elon Wellness ever promise a specific event date that was later postponed or cancelled?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

E2 | Contract Ref: General
Elon's Promise: Were you told services would begin 'next month' more than once without delivery?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

E3 | Contract Ref: General
Elon's Promise: Were you promised a 'Super Event' or special event that was never delivered?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

E4 | Contract Ref: General
Elon's Promise: Did Elon Wellness's attorney ever contact you, and did you receive notice that the attorney withdrew?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

E5 | Contract Ref: General
Elon's Promise: Were you sent a new 'Contract Termination, Repayment and Settlement Agreement' to sign?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

E6 | Contract Ref: General
Elon's Promise: Did you receive any partial payment or reimbursement from Elon Wellness at any point? If yes, how much and when?

Was this delivered?(Required)

Yes

Partial

Details — describe what happened, dates, and any relevant information:

SECTION F — ADDITIONAL COMMENTS & NARRATIVE

In your own words, please describe what Elon Wellness promised you, what was actually delivered, and any other relevant communications or events not covered above:

PROVIDER CERTIFICATION

I certify that the information provided in this questionnaire is true and accurate to the best of my knowledge.

Signature (type full name as signature):(Required)

Printed Name:(Required)

Title / Role:

Date

MM slash DD slash YYYY

⚠ DISCLAIMER: This questionnaire is for informational and documentation purposes only and does not constitute legal advice. We recommend consulting with a licensed attorney in your state for guidance specific to your situation.