WPCA :YK){5-%%*Rr AX&@ZLj#Q"MD5}NSkw+lvd; 1ϨmG-+rUB"ey>KLͽvr]lM)L2yMb7si! f^}G̚j'.dScw_Ms'5 AX,@\S YܠJ4z$6'.dҗ 8Έ'#VvDkqZuta߬c %ܽh~TΘhvqP))ZݰXdHfC^tD|+#@veZ$MFll&#Ewse]%]t<6Bs3 Ĭ$}3~L JFJJNDTr\+#ZUN# %q 0:w^ w4 m\ 0UY 0 0 0J 0 0 0c 0 0 0F 0 0 0} 0$ 0 0` 0 0 0  0 0 09 0 0{ 0 0 01 0<N 0NBrother HL-2040 seriesRR0(9 Z6Times New Roman RegularX($USUS.,S8 e7pdocs"|xU Honeyman-Lowe LLCHoneymanZieger*+ (_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'LetterTXX_Nw zXX_  _Agreement_ԀtoTermsofTelephoneConsultation(s)With___________Dr._ԀJohnC._Lowe,PLLC_  _ ___ ____$X,,XX$_My_Ԁnameis(pleaseprint)______________________________________.Thisformwithmysignatureismyagreementto j thetermsoftelephoneconsultation(s)with___________Dr._ԀJohnC._Lowe,______________PLLC________._ <t l  Iunderstandthe_following: __Ԁ(1)_Ԁ_Dr.LoweischiropractorlicensedinColoradoandTexas.Ihavereadhisbiographyat w www.drlowe.com/jcl/biojcl.htm.(2)UnlessDr.Lowehasexaminedmeinperson,Idonthaveadoctor/patientrelationship K withhim.Instead,myrelationshipwithhimthroughlongdistanceconsultingisahealtheducationandcounseling U relationship.LongdistanceconsultingdoesnotestablishDr.Loweasmyprimarycaredoctor.(2)Dr.Loweisavailableto ' answerquestionsonlyduringscheduledconsultationtimes.     ChargesforConsultations: Iwillfaxthisformcontainingmycontactinformation,creditcardnumber,expirationdate,   andsignaturetoDr.Lowesoffice.IfIprefernottofaxmycreditcardinformation,IwillprovideitbytelephonewhenI g   schedulemyappointment.AfteratelephoneconsultationwithDr.Lowe,Iagreetomycreditcardbeingchargedforthe 9 q  telephoneconsultingfeeandanyotherfeesIagreetothroughthisformorduringtheconsultation.Thefeeforconsultingwill  C  betheappropriatedollaramountforthecumulativetimeoftheconsultation.Therateis$4.25perminute.      ChargeforPreparation: Iunderstandthefollowing:(1)IwillbechargedforthetimeDr.Lowespendspreparingfor   myconsultation(s)byreviewingandconsideringthecontentsofmyrecords.(2)Theamountoftimehemustspend   preparingdependsonthenumberandtypeofdocumentsIprovidepriortoyourevaluation.(3)Iwillbechargedfortimehe U  spendsworkingonmybehalfaftermyconsultationorbetweenconsultations.Thetimemayinvolveresearchonmybehalf '_ thatIrequestofhim,orpreparationofemails,graphs,andotherdocuments,andhisemailingthemtomeorahealthcare 1 practitionerwhomIspecify.(4)Dr.Lowesfeerateisthesameasforthetimehespendstalkingwithmeonthephone,  whichis$4.25perminute.ThesechargesareinadditiontothechargesforthetimeDr.Lowespendswithmeonthe  telephone. o   CancelinganAppointment: Torescheduleorcancelmyappointmentforatelephoneconsultation,Iagreetonotify Ay TammyLoweatleasttwentyfour(24)hoursbeforethescheduledappointment.IfmyappointmentisonMonday,Iwill M phoneorfaxtorescheduleorcancelontheFridaybefore.IfIfailtorescheduleorcanceltwentyfour(24)hoursbeforethe  appointmenttime,orifIdontphoneDr.Lowesconsultationlineatmyappointmenttimeandundergothescheduled  consultation,Iunderstandandagreethatmycreditcardwillbechargedafeeof$127.50forthirty(30)minutesofthetime  thathadbeenreservedforme. ]   HealthHistory&LabResults: Iunderstandthatbeforemytelephoneconsultation(s),IamfreetoprovideDr.Lowe /g withcopiesoflabtestresultsandahealthhistoryandrelatedhealthrecordsthatIfeelareimportantforhimtoreview.Iwill ; sendthesebyfaxto303-496-6200.Itisnotnecessary,however,thatIprovideDr.Lowewithsuchtestresultsorhealth   records.Ԁ(Pleaseseeabove: ChargeforPreparation.)     DisputeResolution: Iunderstandthatthetermsofthisagreementmaybeenforcedagainstanypersonorentity y! associatedwithDr.LowespracticeonlyinMontgomeryCountyinthestateofTexas,UnitedStatesofAmerica,andunder M" theinternallawsofthestateofTexasthejurisdictionofwhichIagreetosubmit.Thecontentsofthisformconstitutethe W# completeagreementbetweenDr.JohnC.Lowe,PLLCandmefortelephoneconsultations,andwhenIsigntheagreement, )$ thetermsoftheagreementwillapplytoanytelephoneconsultationandanyrelatedcommunicationsthroughothermediaI % havewithhim. &   FaxingthisForm&SchedulinganAppointment: Afterfillinginthelinesbelow,Iwillsignthisformandfaxitto g ' 303-496-6200.IfIhavenotalreadyscheduledmytelephoneconsultation,IwillphoneDr.Lowesofficeat6033916061to ;!s ( setthedayandtimeofmyappointment.Atthetimeofmyscheduledconsultation,eitherDr.Lowewillphoneme,orIwill  "E!) phoneDr.Loweconsultationphonenumber(thenumberisavailablethroughTammyLoweat6033916061). ""* 33Signature:______________________________________________________Date:_____________________________ C${#, StreetAddress:_____________________________________City:____________________State:_____Zip:_________ %$. HomePhone:________________________WorkPhone:_________________________Fax:_______________________ 5'm&0 CellPhone:_________________________EmailAddress:_________________________________________________ ('2 CreditCardType:VisaMasterCardCardNumber:___________________________________________________ '*_)4 NameonCard:______________________________________________ExpirationDate:_________________________ +*6 Nameofcardholderifnotyourown(Pleaseprint):________________________________________________________ -Q,8 XSignatureofcardholder(ifnotyourown):____________________________________Date:______________________ .-:   {lzXJohnC.Lowe2008#z{l #