I understand that with the completion of this form I am agreeing to pay $225 per 60-minute appointment with Astrid Pujari, MD, ABIHM, and that I am committing to 1 appointment per month over the next 6 months, schedule permitting, for a total of 6 appointments. I understand that my card will be charged $225 on the 1st of each of the 6 consecutive months that this agreement covers*, even if it is necessary to schedule or reschedule an appointment for a date outside of this period. I agree that I will provide a signed copy of this agreement, as well as a valid credit card number, to the office of Dr. Pujari within one week of requesting this coaching package, at which point the appointments covered by this agreement will be scheduled.
* It may be necessary for some appointments to be charged at time of service, should this agreement be signed in the same month as the first appointment.
I consent to this charge to my card ending in:
I agree to pay the full fee for all coaching appointments, regardless of how many I attend or do not attend, regardless of circumstances. I understand that there are no make-up appointments, and in the event that I need to cancel or reschedule an appointment, I understand that I forfeit the appointment without 48 hours’ notice and any decision by Astrid Pujari, MD PS to refund/forgive any or all of my coaching fee will be made at Dr. Pujari’s sole and absolute discretion. I agree to make every effort to keep the scheduled appointments. I understand I may reschedule appointments, provided I give at least 48 hours’ notice, contingent on Dr. Pujari’s availability.
I understand the coaching appointments are non-refundable, non-transferrable and non-billable to insurance.
I understand that coaching with Dr. Pujari is intended for general education only and is not intended to diagnose or treat any illness or provide any medical advice, diagnosis or treatment. I agree to release and to hold harmless Astrid Pujari, MD, PS from any and all liability, costs, losses, damages or expenses arising from any information provided to me during this coaching program. This release has been signed and submitted by me knowingly and voluntarily, and with full understanding of the terms thereof.
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