WPCo {JA1j&H\Q07 \?%8Rqb Y>CvgcP^. h٨ywS;Tvl>&k섟9b6i\kFZLZ \<@#hjĆ{B|%D=p}6 0 y]jO!u hq&*,Sc067TǺ8+KRX0Y(HJZ<肘Or B}DW_-΁fJ4(z_q<慁2aJw$Cgw߹PQFH,srUzcJCC>]%NnTAKw0nt|Η`R<fD~ 8TBY=DB 4gebPOUܠTS+q(>2ff퇙И x[[v5 C`b;E7#I>'`X$ٖ^>Ν+#ZU N# %q 0:w^ w4Wkz m| 0Uq 0 0 0b 0 0 0{ 0" 0 0^ 0 0 0 0< 0 0x 0  0 0# 0 0 0Q 0 0 0+ 0 0I 0<N   0N!Dell Color Laser 5110cn PCL60(9 Z6Times New Roman RegularX($USUS.,ԗ,< VXYZ[\^`aDbUcDebfbgUhPijDk lDmDnDoUpqrU5:;pdocs"|xrU Honeyman-Lowe LLCHoneymanZiegerconsultee@www.drlowe.com/jcl/biojcl.htm.consultees PLLC*+ (_2623  ..*D+D (_25   ," <DL,23  ..," <DL,   *5+5 (_24  ) <DL)23  ..) <DL)  *2+2 (_23 ` &<<DL&23  ..&<<DL& ` */+/ (_22  #DL#23  ..#DL#  *,+, (_21   DL 23  .. DL  *)+) (_20 h DDL23  ..DDL h *&+& (_19  L23  ..L  *#+# (_18   L23  .. L  *>> (_17  2( 4 <DL223  Ԁ2( 4 <DL2  *DD (_16   ," <DL,23  Ԁ," <DL,   *55 (_15  ) <DL)23  Ԁ) <DL)  *22 (_14 ` &<<DL&23  Ԁ&<<DL& ` *// (_13  #DL#23  Ԁ#DL#  *,, (_12   DL 23  Ԁ DL  *)) (_11 h DDL23  ԀDDL h *&& (_10  L23  ԀL  (## &_9   L23  Ԁ L  (>> &_8  2( 4 <DL223  2( 4 <DL2  (DD &_7   ," <DL,23  ," <DL,   (55 &_6  ) <DL)23  ) <DL)  (22 &_5 ` &<<DL&23  &<<DL& ` (// &_4  #DL#23  #DL#  (,, &_3   DL 23   DL  ()) &_2 h DDL23  DDL h (&& &_1  L23  L  &## $_   L23   L  <:Default Para  , (O$ !USUS.,  _TRX3'Avery 8163 Ink Jet ShippiX3' Letter3'Letter248 Photo Quality3'LetterTXeXe)XX  8dXXd8XX) VVf)PfAgreementtoTermsof  TelephoneEducationalConsultation(s)with  jwithjDr.JohnC.Lowe,PLLCVOV#)XX(#   $X,,XX$h  hMynameis(pleaseprint)____________________i___i__________________.Thisformwithmysignature } belowismyagreementtothetermsoftelephoneeducationalconsultingwithDr.JohnC.Lowe,PLLC.(Below, Ut  consultantreferstoDr.Lowe,and consulteereferstoyouandanyoneelseconsultingwithhimonyourbehalf,as -L thepersonwhoisthebeneficiaryofDr.Loweseducationalconsultingservice.) Iunderstandthefollowing:  $   XX1.NatureofMyConsultation(s)withDr.Lowe:XX (1)IhavereadDr.Lowesbiographyat Ml  www.drlowe.com/jcl/biojcl.htm.(2)Dr.Loweisaresearcherandeducator,notalicensedclinician,andconsulting ) H  withDr.LowedoesnotimplythatIhaveaclinician/patientrelationshipwithhim.Instead,myrelationshipwithhim   throughlongdistanceconsultingisahealtheducationandcounselingrelationship.(3)Iagreetoworkwithmy   currentclinician(s),sharing,ifIwish,theinformationIhavegarneredfrommyconsultation(s)withDr.Lowe.IfIdo   nothavealocalclinician,Iagreetoseekonewhowillprovideclinicalservices,suchasfacetofaceexaminations,ifI   shouldneedthem.(4)IfIneedclinicalservices,especiallyonanemergencybasis,Iagreetoseektheservicesthrough a  alocalclinician,medicalemergencyfacilitysuchasahospitalemergencyroom. 9X    YY2.ChargesforConsultations:Yr Y (1)Iwillfaxthisformcontainingmyagreementinformation,creditcardnumber, 0 expirationdate,andsignaturetoDr.Loweselectronicfaxnumber.IfIprefernottofaxmycreditcardinformation,I   willprovideitbytelephonewhenIschedulemyappointmenttospeakwithDr.Lowe.Afteratelephoneconsultation  withDr.Lowe,IagreethatmycreditcardwillbechargedforthetelephoneconsultingfeeandanyotherfeesIagree  tothroughthisformorduringtheconsultation.Thefeeforconsultingwillbetheappropriatedollaramountforthe u cumulativetimeoftheconsultation.Therateis$4.25perminute.(2)Dr.Loweisnotresponsibleforendingthe Ml telephoneconsultation(s)attheendoftheamountoftimeIprefertoconsult;iftheconsultationextendsbeyondthat %D time,Iamresponsibleforthefeefortheentireaccumulatedtimeoftheconsultation.(3)IagreethatIamheld  responsibleforprovidingavalidmethodofpaymentandintheeventthatmycreditcardchargeisdenied,Iwillbe  subjecttoaninsufficientfeethatwillbeappliedtotheconsultationcharges.    ZZ3.ChargeforPreparation:ZZ (1)IwillbechargedforthetimeDr.Lowespendspreparingformyconsultation(s)  byreviewingandconsideringthecontentsoftherecordsIsubmittohimforreview.(2)Theamountoftimehemust a spendpreparingdependsonthenumberandtypeofdocumentsIprovidepriortomyconsultation.(3)IfIam 9X concernedaboutthecostofthepreparationbyDr.Lowe,aftersubmittingthedocumentsforreview,butbeforethe 0 consultation,Iwillinquireastothecostofpreparation,IwillinquireofTammyLowewhatthecostwillbe;Iwill  eitheragreetopaytheestimatedfeeorstipulateafee;ifIstipulateafee,Iunderstandthatthismaylimitthenumber   ofrecordsIhavesubmittedthatDr.Lowewillbeabletoreviewbeforemyconsultation.(4)Dr.Loweemailsorfaxes ! information(suchasevaluationformsandinstructions)toconsulteeswhenhestatesduringconsultationsthathewill q" doso;hewillnotchargemeforprovidingtheinformation.However,ifheanticipatesthatprovidingtheinformation Ih# willinvolveanamountoftimebeyondwhatiscustomarilyinvolvedinprovidingsuchinformation,Iagreetopaythe !@$ feeinvolved,aslongasDr.Lowe,TammyLowe,orsomeoneelsewhorepresentsthemnotifiesmeofthecharge % beforeheperformstheserviceandIagreetoitbyemailorfax.(FeesaremosttypicallychargedfortimeDr.Lowe  & spendsdoingliteratureorothertypesofresearchonaconsulteesbehalf,preparationofemailsorlettersaddressedto ! ' othersonaconsulteesbehalf,graphsshowingtheresultsoftestresults,andotherdocuments,andhisemailingsuch "!( documentstoothersonmybehalf.)(5)Dr.Lowesfeerateforsuchservicesis$4.25perminute.Thesechargesarein Y#x") additiontothechargesforthetimeDr.Lowespendswithmeonthetelephone. 1$P#*   [[RecordsforDr.LowetoReview:[[ Iunderstandthatbeforemytelephoneconsultation(s),Iamfreetoprovide  %($+ Dr.Lowewithdocumentsforreview;therecordsshouldcontaininformationthatIbelievemaypreparehimto %%, providemewitheducationalinformationrelevanttotheconcernsIwanttoconsulthimabout.Iamfreetoprovide &%- himwithaletterofintroductionaboutmyselfandmyhealthconcerns,alongwithsupportingdocuments,andwitha '&. listofquestionsorconcernsIwouldlikeforhimtoaddress.IwillsendtoDr.Lowetherecordsforreviewbyfaxto m('/ 303-496-6200orbyemailtoTammy@drlowe.com.Itisnotnecessary,however,thatIprovideDr.Lowewithsuch E)d(0 testresultsorhealthrecordsifIchoosenotto. *<)1   \\CancellinganAppointment:\_\ Torescheduleorcancelmyappointmentforatelephoneeducationalconsultation,I **2 agreetonotifyTammyLoweoranotherrepresentativeofDr.Loweatleasttwentyfour(24)hoursbeforethe +*3 m +*3  +*3 ml lm +*3  +*3  +*3  +*3  +*3  +*3 mn +*3   nlUU @ )lkAgreementtoTermsofTelephoneEducationalConsultation(s)withDr.JohnC.Lowe,PLLCklUU#)# ln +*3 a +*3  +*3 nscheduledappointment.IfmyappointmentisonMonday,Iwillphone,email,orfaxtorescheduleorcancelonthe ,+4 Fridaybefore.IwillsendthenoticeofcancellationbyemailtoTammy@drlowe.com,bytelephoneto6033916061, -,5 orbyfaxto3034966200.IfIfailtorescheduleorcanceltwentyfour(24)hoursbeforetheappointmenttime,Io Y.x-6 )P ),X )  op )pq  qpAgreementtoTermsofTelephoneEducationalConsultation(s)withDr.JohnC.Lowe,PLLC #)!#!po  oq "qoorragreethatmycreditcardwillbechargedafeeof$127.50forthirty(30)minutesofthetimethathadbeenreserved < forme.    ^^DisputeResolution:^#^ Iunderstandthatthetermsofthisagreementmaybeenforcedagainstanypersonorentity  associatedwithDr.LowespracticeonlyinMontgomeryCountyinthestateofTexas,UnitedStatesofAmerica,and  undertheinternallawsofthestateofTexasthejurisdictionofwhichIagreetosubmit.Thecontentsofthisform  constitutethecompleteagreementbetweenDr.JohnC.Lowe,PLLCandmefortelephoneconsultations,preparation, Yx  andwhenIsigntheagreement,thetermsoftheagreementwillapplytoanytelephoneconsultationandanyrelated 1 P  communicationsthroughothermediaIhavewithhim.  (    ``FaxingthisForm&SchedulinganAppointment:`&` Afterfillinginthelinesbelow,Iwillsignthisformandfax   itto303-496-6200.IfIhavenotalreadyscheduledmytelephoneconsultation,IwillphoneDr.Lowesmain   telephonenumber.6033916061,tosetthedayandtimeofmyappointment.Atthetimeofmyscheduled   consultation,eitherDr.Lowewillphoneme,orIwillphoneDr.Lowesconsultationphonenumber2813234086or m  anothernumberifTammyprovidesone. Ed     XX)ContactandCreditCardInformation #)X)#)   s)Signature:_________________________________________________Date:_____________________________  StreetAddress:_________________________________________City:_______________________State:_____ A` Zip:____________HomePhone:__________________________WorkPhone:___________________________  EFax:_____________________CellPhone:_________________________Email________________________  CreditCardType:VisaMasterCardCardNumber:______________________________________________   NameonCard:_________________________________________ExpirationDate:_________________________ ! Nameofcardholderifnotyourown(Pleaseprint):___________________________________________________ a# Signatureofcardholder(ifnotyourown):__________________________________Date:___________________  0%   e )=*Xggaabbcb A,`+7 bcJohnC.Lowe2010#) e ).#