THYROID POWER-Coaching Session Agreement

<body topmargin="0" leftmargin="0"> <p align="center"><font face="Arial"><b>This page uses frames, but your browser doesn't support them. You will have to scroll to bottom to navigate.</b></font></p> <table border="0" cellpadding="0" cellspacing="0" align="center" width="635"> <tr> <td width="635"> <center> <table border="0" cellpadding="0" cellspacing="0" width="635"> <tr> <td width="94"><img border="0" src="images/richsm.jpg" width="94" height="122"></td> <td> <p align="center"><img border="0" src="images/TITLE.jpg" width="431" height="92"> </td> <td width="94"> <img border="0" src="images/karileesm.jpg" width="94" height="122"> </td> </tr> <tr> <td width="94" valign="top" align="left"><font face="Arial" size="2"><b>Richard L. Shames, M.D.</b></font></td> <td> <p align="center"> </td> <td width="94"> <p align="left"><b><font size="2" face="Arial">Karilee H. Shames, R.N., Ph.D.</font></b> </td> </tr> </table> </center> <table border="0" cellpadding="0" cellspacing="0" width="635"> <tr> <td colspan="2" width="635"> <p align="center"><B><font face="Times New Roman" size="6" color="#AA003C">THYROID COACHING AGREEMENT</font></b></td> </tr> <tr> <td colspan="2" width="635" height="30"> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <p align="center"><font face="Arial" size="4"><b>THERE HAVE BEEN SOME RECENT CHANGES (<font color="#AA003C">May 27, 2003</font>)<br> SO PLEASE READ THIS PAGE CAREFULLY</b></font></td> </tr> <tr> <td colspan="2" width="635" height="30"> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <p align="center"><font face="Arial"><b> (For Information on Coaching Sessions, see <a href="consultsfr.html">Coaching Sessions</a> )<br> (<a href="frequentfr.html">Frequently Asked Questions</a>)</b></font></td> </tr> <tr> <td colspan="2" width="635" height="30"></td> </tr> <tr> <td colspan="2" width="635" height="30"><font face="Arial"><b><font color="#D6004A"><a href="biosfr.html#richard">Dr. Richard Shames</a></font> is a Harvard and University of Pennsylvania educated practicing MD who specializes in optimal hormone balancing, especially individualized thyroid care. <BR> <BR> <font size="4"><font color="#AA003C">THYROID POWER</font> COACHING AGREEMENT ($250)*.</font></b></font> </td> </tr> <tr> <td colspan="2" width="635" height="30"> </td> </tr> <tr> <td colspan="2" width="635" height="50"><b><font face="Arial" size="4"><font color="#AA003C">Print</font> Out <font color="#AA003C">One</font> of the Following:</font></b></td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <font face="Arial"><b>One-page Microsoft Word Format -- <a href="consultform.doc">Download the Agreement Now</a></b></font></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <b><font face="Arial">One-page Adobe PDF Format -- <a href="agreemnt.pdf">Download the Agreement Now</a></font></b></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <b><font face="Arial">One-page </font></b><font face="Arial" size="3"><b> <a href="printeragreement.html">Print Now Version</a></b></font></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <p><b><font face="Arial" size="4"><font color="#AA003C">Fill</font><font color="#D6004A"> </font>Out the Consent Agreement Completely-</font></b></p> <p><font face="Arial" size="4"><b><font color="#AA003C">Fax</font> the Entire Agreement to <font color="#AA003C">(415) 472-</font></b><font color="#AA003C"><b>7636</b></font></font><font face="Arial" size="3"><b>***NEW NUMBER***</b></font> </p> <p><font face="Arial"><b>Then <font color="#AA003C">CALL 415-472-2343</font> to schedule a Tuesday appointment  for your coaching session with Dr. Shames. <font color="#AA003C">***NEW***</font></b></font></p> <p><font face="Arial"><b> If you need further information to make sure a Thyroid Coaching Session is right for you, <font color="#AA003C">CALL</font> 866-468-4979.</b></font></p> </td> </tr> <tr> <td colspan="2" width="635" height="50"> <p align="center"><img border="0" src="images/divider.gif" width="500" height="9"></td> </tr> <tr> <td colspan="2" width="635" height="30"><b><font face="Arial" color="#AA003C" size="4">CONSENT TO COACHING SESSIONS WITH DR. RICHARD SHAMES</font></b></td> </tr> <tr> <td colspan="2" width="635" height="30"></td> </tr> <tr> <td colspan="2" width="635" height="30"> <P><font face="Arial"><b> I, ________________________________________, <BR> (print name legibly)<BR> <BR> fully understand that this form constitutes my agreement to purchase a 50 minute health coaching session from Richard Shames MD. <BR> <BR> I agree to work directly and regularly with a primary care doctor in my local vicinity, who will manage my ongoing medical care. I understand that Dr.Shames' health coaching services do not replace individual medical care in any way, but instead constitute a health education opportunity - not the diagnosis and treatment of an illness. I understand that Dr. Shames is not available for questions except during scheduled follow-up phone appointments. <BR> <BR> I further agree that at the time of faxing this form, with my credit card number and signature on it, my credit card will be charged $250 ($150 for a 25 minute re-consult) to hold an appointment slot for me, and that I will call 415-472-2343 between 9am-5pm (PST) to schedule the exact time of the appointment (Coaching sessions are scheduled for Tuesdays). It is further understood that should I need to later change my appointment time, I will have one opportunity only to reschedule without a fee, as long as I have called to reschedule more than 72 hours in advance (3 days). (NOTE: Calls made on weekends will be considered calls made on Monday, you must cancel by Friday  before the time you are scheduled on the following Tuesday.) </b></font><img border="0" src="images/star.gif" width="15" height="15"><font face="Arial" size="3"><b>I understand that once my form is faxed and my credit card charged, there will be no refunds only possible re-scheduling</b></font> </P> <P><font face="Arial"><b>I understand that I will also be able to fax a maximum of six (6) pages of lab results, to be reviewed by Dr. Shames.<BR> <BR> I understand that if I for some reason miss my scheduled discussion appointment, or have to cancel with less than 3 days notice, I am still liable for the $250 fee. I will call to reschedule another appointment within 3 months of my scheduled appointment, and understand that Dr. Shames will make every effort to save time for a 25 - minute make-up session as soon as possible after my cancellation, but that there is no guarantee that I will be able to be scheduled without having to pay for another coaching session. <BR> <BR> I understand that Dr. Shames is not available for questions except during scheduled follow-up phone appointments. <BR> <BR> I understand that by signing this contract, I am bound to pay for informational educational services only, and will so do and submit to the jurisdiction of the State of California where the information is disseminated. I have supplied a witness signature, my credit card number, as well as my own signature below. <br> <br> This contract may only be enforced against all persons and entities associated with Thyroid Power in the state of California, County of Marin, and under the internal laws of the state of CA. This constitutes the complete contract between myself and Thyroid Power for telephone discussion only. <br> <br> Nothing in Thyroid Power e-mail communications nor in Thyroid Power web pages should be construed as medical diagnosis or treatment. No doctor-patient relationship is established by these e-mail or telephone contacts. I agree to consult with my own doctor for diagnosis and treatment specific to my particular case. For a full disclaimer, <a href="../thyroidpower/disclaimer.html">click here</a>. <br> <br> All lines must be filled in below, and must have a witness signature to be processed. <img border="0" src="images/star.gif" width="15" height="15"> If the Formal Name on the credit card is different from the person seeking coaching-we must have the signature of the person whose name is on the credit card, also. </b></font></P> <P><font face="Arial"><b>To schedule your 50 minute session, fill out the Thyroid Coaching Session Request Form now, and Fax it to: 415-472-7636. Then Call 415-472-2343 between 9am-5pm(PST)  to schedule a Tuesday appointment for your coaching session with Dr. Shames.  </b></font></P> </td> </tr> <tr> <td colspan="2" width="635"> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="2" WIDTH="600"> <TR> <TD> <P>___________________________________________________</TD> </TR> <TR> <TD>Print name above</TD> </TR> <TR> <TD> <P>____________________________________________________</TD> </TR> <TR> <TD>Signature and date above</TD> </TR> <TR> <TD> <P>___________________________________________________</TD> </TR> <TR> <TD>Print witness name above</TD> </TR> <TR> <TD> <P>____________________________________________________</TD> </TR> <TR> <TD>Witness signature and date above</TD> </TR> </TABLE> </td> </tr> <tr> <td height="50" colspan="2" width="635">   <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="2" WIDTH="635"> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">NAME OF LOCAL DOCTOR</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">YOUR HOME ADDRESS </TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">CITY, STATE, ZIP</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">HOME PHONE</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">WORK PHONE</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">CELL PHONE</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">EMAIL</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">FAX</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">BEST TIMES TO CALL</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">CREDIT CARD NUMBER</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">EXPIRATION DATE</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">FORMAL NAME ON CARD</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">SIGNATURE OF CARD HOLDER<br> (if different from above)</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">TYPE OF CARD (visa, mc, etc)</TD> <TD width="356">_____________________________________</TD> </TR> <TR> <TD WIDTH="232" ALIGN="LEFT" VALIGN="TOP">How did you hear about Dr. Shames?</TD> <TD width="356">_____________________________________</TD> </TR> </TABLE> </td> </tr> <tr> <td height="50" colspan="2" width="635"> <p>  </td> </tr> <tr> <td colspan="2" width="635" height="50"><b><font face="Arial" size="4"><font color="#AA003C">Print</font> Out <font color="#AA003C">One</font> of the Following:</font></b></td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <font face="Arial"><b>One-page Microsoft Word Format -- <a href="consultform.doc">Download the Agreement Now</a></b></font></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <b><font face="Arial">One-page Adobe PDF Format -- <a href="agreemnt.pdf">Download the Agreement Now</a></font></b></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <blockquote> <p><img border="0" src="images/bullet.jpg" width="12" height="12">   <b><font face="Arial">Two-page</font></b><font face="Arial" size="3"><b> <a href="printeragreement.html">Print Now Version</a></b></font></p> </blockquote> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <p><b><font face="Arial" size="4"><font color="#AA003C">Fill</font><font color="#D6004A"> </font>Out the Consent Agreement Completely- </font></b></p> <p><b><font face="Arial" size="4"><font color="#AA003C">Fax</font> the Entire Agreement to <font color="#AA003C">(415) 472-7636 </font></font><font face="Arial" size="3">***NEW NUMBER***</font></b> <p><font face="Arial"><b>Then <font color="#AA003C">CALL 415-472-2343 </font>between 9am-5pm (PST) to schedule a <font color="#AA003C">TUESDAY</font> appointment  for your coaching session with Dr. Shames. <font color="#AA003C">***NEW***</font></b></font></p> <p><font face="Arial"><b> If you need further information to make sure a Thyroid Coaching Session is right for you, <font color="#AA003C">CALL</font> 866-468-4979.</b></font></p> </td> </tr> <tr> <td colspan="2" width="635" height="50"> <p align="center"><img border="0" src="images/divider.gif" width="500" height="9"> </td> </tr> <tr> <td colspan="2" width="635" height="30"> <p align="center"> <center> <b><font face="Arial" size="4">GIVE YOURSELF<font color="#D6004A"> </font><font color="#AA003C"> THE GIFT OF HEALTH</font>! <br> WE'RE HERE TO <a href="consultsfr.html">HELP</a></font></b></center> </td> </tr> <tr> <td height="50" colspan="2" width="635"> <p align="center"><img border="0" src="images/divider.gif" width="500" height="9"> </td> </tr> <tr> <td width="317"> <p align="center"><img border="0" src="images/Coversm.gif" width="100" height="151"> <br> <font face="Arial" size="2"><b>Harper Collins, 2001</b></font> </td> <td width="318"> <p align="center"><img border="0" src="images/book2sm.gif" width="100" height="151"> <br> <font face="Arial" size="2"><b>Harper Collins, 2002</b></font> </td> </tr> <tr> <td colspan="2" width="635"> <p align="center"> </p> <p align="center"> <CENTER> <font size="4"><font face="Arial">To purchase </font> <B><font color="#AA003C" face="Arial">THYROID </font><font face="Arial"><font color="#AA003C">POWER</font>,</font></B><font face="Arial"> </font><br> </font><font size="3"><b><font face="Arial"> visit <a href="http://www.amazon.com/exec/obidos/ASIN/0060082224/shameshealth-20" target="_blank">Amazon.com</a> or <a href="http://service.bfast.com/bfast/click?bfmid=2181&sourceid=39583754&bfpid=0688172369&bfmtype=book" target="_blank">BarnesandNoble.com</A> or visit your local bookstore.</font><br> </b></font> <font size="2"> <br> <font face="Arial"><b><a href="disclaimerfr.html">Please see our disclaimer</a>.</b></font></font> </center> </td> </tr> <tr> <td height="50" colspan="2" width="635"> <p align="center"><img border="0" src="images/divider.gif" width="500" height="9"> </td> </tr> <tr> <td colspan="2" width="633" height="30"> <p align="center"><font face="Arial" size="1"><b>l <a href="index.html">HOME</a> l <a href="cartoonsfr.html">CARTOONS</a> l <a 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href="http://www.witticismsink.com" target="_blank" ONMOUSEOVER="OnImage('img01');" ONMOUSEOUT="OffImage('img01');"><img border="0" name="img01" src="images/newlogoa.jpg" alt="For any questions and comments on the website or to report errors CLICK HERE-www.witticismsink.com" width="108" height="38"><br> </a><b><font size="1"><font FACE="Symbol">Ó </font><font face="Arial">October 2002</font></font></b> <p align="center"><b><font face="Arial" size="2">Updated May 27, 2003</font></b> <p align="center"><a href="http://www.witticismsink.com" target="_blank" ONMOUSEOVER="OnImage('img01');" ONMOUSEOUT="OffImage('img01');"><br> </a></td> </table> <p align="center">  </td> </tr> </table> </td> </tr> </table> </body>