By signing this form, I, the above, understand and agree to the following:

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Dr. Astrid Pujari and her medical and intuitive coaching practice known as Astrid Pujari MD (both will referred to here, either individually or in conjunction, as DR. PUJARI) is not serving as a primary care physician, but as a consultant. Using the services of DR. PUJARI requires that I have a primary care doctor in my state to serve me regarding my medical concerns. For emergencies, I understand that I must go to the emergency room or call 911.

 

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The cost of an Integrative Medical Coaching Package is $1,999.00 if paid in full on registration, or, if paying monthly, $215.00 per month for a total of $2,580.

 

If paying monthly, the first payment must be paid before the first set of labs is done, and will be equal to 2 months’ payment, for a total of $430.00. After the first payment, $215.00 will be charged to my credit card on file on the first day of each month, beginning the month after the first payment, and continuing for the next 10 consecutive months, until my payment obligation is complete. Please initial below to indicate which payment plan you choose.

 

 I agree that in order to finalize my registration I must provide a signed copy of this agreement as well as a valid credit card number to the office of DR. PUJARI. I will also provide all additional paperwork requested of me and submit any health documentation that may be relevant so that DR. PUJARI may review it prior to your first appointment.

 

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I understand that I am responsible for scheduling and completing all the elements of this package within 365 days (1 year) of signing this contract. If for any reason, I do not complete any of the elements of this package within 365 days, I hold DR. PUJARI harmless and I forfeit any incomplete elements with no refund. I understand that if I do not complete any element of this package within the designated time period, I will have to pay the full amount regardless of circumstances.

 

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Elements included in this package are the following:

• One (1) 90-minute intake with DR. PUJARI

• Two (2) 55-minute appointments with DR. PUJARI

• One (1) 1-hour consultation with Emily Ziedman, MS, CN, AWC, a Certified Nutritionist

• Two (2) sets of baseline labs

• If I have had labs run recently through my doctor and do not wish to do more lab work, I may exchange one set of labs for an additional 1-hour consultation with Emily Ziedman, MS, CN, AWC, or both sets of labs for 2 additional 1-hour consultations with her. If I choose this option, I must notify Dr. Pujari’s office by month three of the package (within 90 days after signing this contract).

 

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My first set of baseline labs will be done prior to my first appointment, and the second one will be done at the midpoint of my medical coaching package. As described in detail in section #4, I may substitute one baseline set of labs with one nutrition appointment with Emily Ziedman. My labs will entail having my blood drawn at a LabCorp location of my choosing. I understand that the exact labs drawn are part of a standardized set, which are intended to provide an overview and screening of general health, and are predetermined by DR. PUJARI, and not able to be changed. I understand that ANY additional labs beyond those specified in the package that are recommended based on health conditions discussed in my appointments or requested by me, WILL NOT be covered as part of the package cost, and I will be required to pay additionally for those labs. Please initial below to indicate that you understand and agree to the terms of getting lab work done.

 

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Appointments with DR. PUJARI will be conducted either virtually, or in-person. In-person visits are available ONLY at her office at 20006 Cedar Valley Road, Ste. 203, Lynnwood, WA 98036.

 

The nutrition consultation with Emily Ziedman, MS, CN, AWC, is a 1-hour visit, and is virtual only.

 

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DR. PUJARI and all employees and affiliates do not take any responsibility for actions I take, nor any harm or damage suffered resulting from the use or non-use of the information available in an appointment, on the website, in handouts or written materials, or in classes. I agree to use judgment and conduct due diligence before taking any action or implementing any plan or practice suggested or recommended.

 

DR. PUJARI does not make any guarantees about the results of the information applied and shares educational and informational resources that are intended to help me succeed in wellbeing, health, and fitness. I understand that my ultimate success or failure will be the result of my own efforts, my particular situation, and innumerable other circumstances beyond DR. PUJARI’s knowledge or control.

 

I agree to always seek advice from my primary care physician before undertaking a new health regimen.

 

I agree that I will not disregard medical advice or delay seeking medical advice because of information provided by DR. PUJARI. I will not start or stop any medications without speaking to my medical or mental health provider. 

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DR. PUJARI does not bill your insurance directly for any services provided. Once my Integrative Medical Coaching Package has been paid in full, I may request that DR. PUJARI send me a “super bill” to submit to my insurance company for potential reimbursement, provided I:

• Live in Washington state.

• Understand that my super bill includes my appointments with DR. PUJRI only, at a rate of $385.00 per appointment, and a total of $1,155.00. All other services included in the Integrative Medical Coaching Package are not eligible for potential reimbursement.

• Understand that DR. PUJARI does not guarantee that my insurance company will reimburse me for any appointments, and that researching my policy, submitting my claim, and communicating with my insurance company is my sole responsibility.

 

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This Integrative Medical Coaching Package is nonrefundable or transferable.

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I understand that I may not be eligible for a medical coaching appointment, and should that be the case, this agreement is null and void and will be destroyed by the office of Astrid Pujari, MD.

 

 

Please provide the requested information and your signature below. By signing this agreement, you signify that you have read and understood all information therein and agree to all terms and conditions.​

 

IF YOU HAVE NOT SEEN DR. PUJARI WITHIN THE LAST 5 YEARS, PLEASE ALSO FILL OUT A NEW CLIENT FORM AND SUBMIT IT AT LEAST 3 DAYS PRIOR TO YOUR INTAKE APPOINTMENT.

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