Name

First Name

Last Name

Email Address

Date

YYYY

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

Phone

Signed and Agreed

First Name

Last Name

Date

YYYY