Wellness Consultation
Consent to Coaching Session with Patrick W. Hart, Jr., N.M.D., M.P.H.
To schedule an appointment please contact Dr. Skip at 972-530-4609
I,______________________________________, fully understand that this form constitutes my agreement to purchase a 50-minute health coaching & wellness session from Patrick W. Hart, Jr., N.M.D., M.P.H. 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. Hart’s 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. Hart 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 then call 972-530-4609 between 9am-5pm (CST) to schedule the exact time of the appointment (Coaching Sessions are scheduled for Mondays through Friday). 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. Hart.
I understand that if I for some reason I 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. Hart will make every effort to save time for a 25 – minute make-up session as soon as possible after my cancellation, and 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. Hart 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 Texas where the information is disseminated. I have supplied a witness signature, my credit card number, as well as my own signature below. I also understand that Patrick W. Hart, Jr., N.M.D. is a Naturopathic Physician & Doctor of Oriental Medicine and NOT a medical doctor.
This contract may only be enforced against all persons and entities associated with AskDrSkip.com in the state of Texas, County of Collin, and under the internal laws of the state of TX. This constitutes the complete contract between myself and Dr. Skip of AskDrSkip.com for telephone discussion only.
Nothing in AskDrSkip.com, e-mail communications or AskDrSkip.com 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. Please see the “disclaimer” section of askdrskip.com for additional information.
To schedule your 50-minute session, fill out the Coaching Session Request Form now. All lines must be filled in below, and must have a witness signature to be processed. Then call 972-530-4609 between 9am-5pm (CST) to schedule a Monday-Friday appointment (or by special after hours appt.) for your coaching session with Dr. Hart. YOU will be given a phone number for YOU to call Dr. Hart at your appointment time!
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Name & Signature / Date
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Witness Name & Witness Signature / Date
Your 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: __________________________________
Name on Card: __________________________________________
Expiration Date: _______________
Signature of Card Holder-if different from coachee
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How did you hear about Dr. Hart?
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