Name *
Name
Date *
Date
Phone *
Phone
Consent to Contact You to Schedule a Face to Face Consultation
I (The Client) agree that this authorization shall serve as consent for Dr. James D. Wellman to contact me by email or phone to schedule a face to face consultation.
Ackknowledgement of My Preferred Method of Contact *
Signed and Agreed *
Signed and Agreed
Date *
Date