Agreement to Terms of Telephone Consultations with Dr. John C. Lowe, PLLC

Agreement to Terms of Telephone Consultation(s) With Dr. John C. Lowe, PLLC

My name is (please print)______________________________________. This form with my signature is my agreement to the terms of telephone consultation(s) with Dr. John C. Lowe, PLLC.

I understand the following: (1) Dr. Lowe is chiropractor licensed in Texas, USA. I have read his biography at www.drlowe.com/jcl/biojcl.htm. (2) Unless Dr. Lowe has examined me in person, I don’t have a doctor/patient relationship with him. Instead, my relationship with him through long-distance consulting is a health education and counseling relationship. Long-distance consulting does not establish Dr. Lowe as my primary care doctor. (2) Dr. Lowe is available to answer questions only during scheduled consultation times.

Charges for Consultations: I will fax this form containing my contact information, credit card number, expiration date, and signature to Dr. Lowe’s office. If I prefer not to fax my credit card information, I will provide it by telephone when I schedule my appointment. After a telephone consultation with Dr. Lowe, I agree to my credit card being charged for the telephone consulting fee and any other fees I agree to through this form or during the consultation. The fee for consulting will be the appropriate dollar amount for the cumulative time of the consultation. The rate is $4.25 per minute.

Charge for Preparation: I understand the following: (1) I will be charged for the time Dr. Lowe spends preparing for my consultation(s) by reviewing and considering the contents of my records. (2) The amount of time he must spend preparing depends on the number and type of documents I provide prior to your evaluation. (3) I will be charged for time he spends working on my behalf after my consultation or between consultations. The time may involve research on my behalf that I request of him, or preparation of emails, graphs, and other documents, and his emailing them to me or a health care practitioner whom I specify. (4) Dr. Lowe’s fee rate is the same as for the time he spends talking with me on the phone, which is $4.25 per minute. These charges are in addition to the charges for the time Dr. Lowe spends with me on the telephone.

Canceling an Appointment: To reschedule or cancel my appointment for a telephone consultation, I agree to notify Tammy Lowe at least twenty-four (24) hours before the scheduled appointment. If my appointment is on Monday, I will phone or fax to reschedule or cancel on the Friday before. If I fail to reschedule or cancel twenty-four (24) hours before the appointment time, or if I don’t phone Dr. Lowe’s consultation line at my appointment time and undergo the scheduled consultation, I understand and agree that my credit card will be charged a fee of $127.50 for thirty (30) minutes of the time that had been reserved for me.

Health History & Lab Results: I understand that before my telephone consultation(s), I am free to provide Dr. Lowe with copies of lab test results and a health history and related health records that I feel are important for him to review. I will send these by fax to 303-496-6200. It is not necessary, however, that I provide Dr. Lowe with such test results or health records. (Please see above: "Charge for Preparation.")

Dispute Resolution: I understand that the terms of this agreement may be enforced against any person or entity associated with Dr. Lowe’s practice only in Montgomery County in the state of Texas, United States of America, and under the internal laws of the state of Texas the jurisdiction of which I agree to submit. The contents of this form constitute the complete agreement between Dr. John C. Lowe, PLLC and me for telephone consultations, and when I sign the agreement, the terms of the agreement will apply to any telephone consultation and any related communications through other media I have with him.

Faxing this Form & Scheduling an Appointment: After filling in the lines below, I will sign this form and fax it to 303-496-6200. If I have not already scheduled my telephone consultation, I will phone Dr. Lowe’s office at 603-391-6061 to set the day and time of my appointment. At the time of my scheduled consultation, either Dr. Lowe will phone me, or I will phone Dr. Lowe consultation phone number (the number is available through Tammy Lowe at 603-391-6061).

Signature:______________________________________________________ Date:_____________________________

Street Address:_____________________________________ City:____________________ State:_____ Zip:_________

Home Phone:________________________ Work Phone:_________________________Fax:_______________________

Cell Phone:_________________________ E-mail Address:_________________________________________________

Credit Card Type: Visa MasterCard Card Number: ___________________________________________________

Name on Card:______________________________________________ Expiration Date:_________________________

Name of card holder if not your own (Please print):________________________________________________________

Signature of card holder (if not your own):____________________________________ Date:______________________