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Fill Out
the Consent Agreement Completely-
Fax
the Entire Agreement to (415) 472-7636
Then CALL
415-472-2343 to schedule a
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
CALL 866-468-4979.
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I, ________________________________________,
(print name legibly)
fully understand that this form constitutes my agreement to purchase
a 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
(either $270 for Initial Coaching- 50 minutes or $170 for
Follow-up Coaching-25 minutes) to hold an appointment slot for me, and that I
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). (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-schedules.
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 persons and entities associated with
Shames Family Services 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
Shames Health Services for telephone discussion only.
Nothing in our e-mail communications nor in Shames Family
Services 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 session, fill out the Coaching
Session Request Form below, and
Fax it to:
415-472-7636. Then Call 415-472-2343 between
9am-5pm(PST) to schedule a
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 YOUR APPOINTMENT TIME!
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|
Fill Out
the Consent Agreement Completely-
Fax
the Entire Agreement to (415) 472-7636
Then CALL
415-472-2343 between 9am-5pm (PST) to schedule a
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
CALL 866-468-4979.
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