I agree to pay $275 for one 60-minute appointment with Astrid Pujari, MD, ABIHM.

I agree to return this signed agreement, along with any other requested paperwork, to the office of Dr. Pujari within one week of my appointment, and failure to do so may result in my appointment being cancelled.

I also agree to provide a valid credit card number to the office of Dr. Pujari within one week of my appointment. Failure to do so will result in my appointment being cancelled. I understand that my credit card may be charged prior to my appointment at any time within, but not before, 48 hours of my appointment.

I understand that 48 hours’ notice is required for rescheduling or cancelling appointments, and if I cancel or reschedule within 48 hours of my appointment, or miss it for any reason, I will be charged in full.

I understand my appointment is 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 appointment. This release has been signed and submitted by me knowingly and voluntarily, and with full understanding of the terms thereof.