Consent to Coaching Session with Dr. Richard Shames
I, ______________________________________, 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 then 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: 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, see: http://www.thyroidpower.com/disclaimer.html 
To schedule your 50 minute session, fill out the Thyroid Coaching Session Request Form now. All lines must be filled in below, and must have a witness signature to be processed. Fax it to: 415-472-7636. Then call 415-472-2343 between 9am-5pm PST to schedule a  Monday/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.
__________________________________________
Print Name		 ________________________________________________
Signature and Date  
__________________________________________
Print Witness Name      		 ________________________________________________
Witness Signature and Date 
Name of Local Doctor:        ________________________________________________________________________
Your Street Address:          ________________________________________________________________________  
City, State, Zip                     ________________________________________________________________________  
Home Phone, Work Phone: ________________________________________________________________________  
Cell Phone, Fax:                     ________________________________________________________________________  
Email Address:                      __________________________     Best Times to Call _____________________________
Type of Card:                        __________________    Credit Card Number: ____________________________________  
Formal Name on Card: __________________________________________ Expiration Date: ____________________
Signature of Card Holder (if different from "coachee" above)_______________________________________________
How did you hear about Dr. Shames? ________________________________________________________________

PLEASE FAX ENTIRE AGREEMENT TO 415-472-7636