THYROID COACHING AGREEMENT

GOOD NEWS FOR THE NEW YEAR!

DR SHAMES HAS EXPANDED HIS PHONE TIME TO MEET THE INCREASED DEMANDS FOR TELEPHONE COACHING
AND IS NOW PROVIDING MORE INFORMATION TO HELP PEOPLE GET STARTED ON THEIR HEALTH PROGRAM
WITH NATURAL PRODUCTS AND TESTING RIGHT AWAY!.

(For Information on Coaching Sessions, see Coaching Sessions )
(Frequently Asked Questions)

   One-page Microsoft Word Format -- Download the Agreement Now

   One-page Adobe PDF Format -- Download the Agreement Now

   One-page  Print Now Version

Fill Out the Consent Agreement Completely-

Fax the Entire Agreement to (415) 472-7636***NEW NUMBER***

Then CALL 415-472-2343 to schedule a (**NEW**)Monday or Tuesday appointment  for your coaching session with Dr. Shames. 

YOU WILL BE GIVEN A PHONE NUMBER FOR YOU TO CALL DR. SHAMES AT THE TIME OF YOUR APPOINTMENT!

If you need further information to make sure a Thyroid Coaching Session is right for you, CALL 866-468-4979.

I, ________________________________________,
(print name legibly)

fully understand that this form constitutes my agreement to purchase a 50 minute health coaching session from Richard Shames MD.

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.

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 $270 ($170 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 Mondays or 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 Thursday/Friday  before the time you are scheduled on the following Monday/Tuesday (respectively.) I understand that once my form is faxed and my credit card charged, there will be no refunds only possible re-scheduling

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.

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 $270 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.

I understand that Dr. Shames is not available for questions except during scheduled follow-up phone appointments.

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.

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.

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, click here.

All lines must be filled in below, and must have a witness signature to be processed. 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. 

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 Monday(***NEW***) or Tuesday appointment for your coaching session with Dr. Shames. YOU WILL BE GIVEN A PHONE NUMBER FOR YOU TO CALL  DR. SHAMES AT YOUR APPOINTMENT TIME! NO MEDICARE BILLING OR REIMBURSEMENT IS POSSIBLE.

   One-page Microsoft Word Format -- Download the Agreement Now

   One-page Adobe PDF Format -- Download the Agreement Now

   Two-page Print Now Version

Fill Out the Consent Agreement Completely-

Fax the Entire Agreement to (415) 472-7636 ***NEW NUMBER***

Then CALL 415-472-2343 between 9am-5pm (PST) to schedule a MONDAY(**NEW**) or TUESDAY appointment  for your coaching session with Dr. Shames. 

YOU WILL BE GIVEN A PHONE NUMBER FOR YOU TO CALL DR. SHAMES AT THE TIME OF YOUR APPOINTMENT!

GOOD NEWS FOR THE NEW YEAR--Dr Shames has expanded his phone time to meet the increased demands for Telephone Coaching.... and is now providing More information to help people get started on their health program with natural products and testing right away!

If you need further information to make sure a Thyroid Coaching Session is right for you, CALL 866-468-4979.

Harper Collins, 2001

Harper Collins, 2002

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