HORMONE SALIVA TEST + One-on-One Consult

YES! SIGN ME UP!

For a One-on-One Personal Consult to review test results and discuss the best solution to GET BACK on TRACK and YES - REVERSE AGING!

Understand your results and discover how to balance your hormones safely and effectively. One Hour Time Block is Reserved for you!

INCLUDES:
Saliva Profile One (with added E1 & E3) Hormone Test Kit Shipped to You + ONE-On-ONE with Dr. Karen and Nurse Practitioner Leah

Total: $780
(or choose 2 Payments of $400 each)

Let's Get Started!

Please enter your billing address below:

First Name *

Last Name *

Billing Street Address *

Address Line 2

City *

State *

Billing Zip Code *

Phone Number *

Email Address *

Payment Options

Total Payment Due: *

Single Payment of $780

Two Payments of $400, one now and one 30 days from now

Credit Card Information (If Paying by Credit Card)

Credit Card Type

Name on Card

Credit Card Number

Expiration Date

Security Code

Checking Account Information (If Paying by Check Draft)

Name of Bank

Name on Checking Account

Routing Number (from your check)

Checking Account Number

Confirm Checking Account Number

Notice

NOTICE: Though you may have seen this product/program listed on www.womensmidlifespecialist.com, the product/program is administered through Personal Wellness Medicine, LLC (PWM).

Disclaimer

I acknowledge and agree to the following:

Personal Wellness Medicine, LLC (PWM) is a medical practice registered to conduct business in the State of Florida. Personal Wellness Medicine, LLC is NOT credentialled with Medicare, Medicaid, or any commercial insurance company. No personal services or information provided by Personal Wellness Medicine, LLC or Karen F. Leggett, D.O. through Personal Wellness Medicine, LLC are reimbursable by Medicare, Medicaid, or any commercial insurance company. Medicare, Medicaid, and commercial insurance companies Will Not pay for services provided by Personal Wellness Medicine, LLC or Karen F. Leggett, D.O. through Personal Wellness Medicine, LLC. Personal Wellness Medicine, LLC cannot provide me with any kind of statement or invoice that can be submitted to Medicare, Medicaid, or any commercial insurance company.

Dr. Karen Leggett will be providing advice to me as a specialist, limited to the interpretation of ZRT Lab test results and suggestions based on those results. There will not be a doctor-patient relationship between me and Dr. Karen Leggett. Dr. Karen Leggett will not be my primary care provider (PCP), nor will she assume the role of my PCP at any time.

If, at any time, advice from Dr. Karen Leggett conflicts with medical care or advice from my PCP, it will be my choice and my responsibility to decide which advice to follow.

Signature - Use Your Mouse (or finger on a touch screen) *

clear

Notice: Submitting this form will not initiate an immediate charge on your account. Rather, your financial information will be encrypted and transferred to an Intuit QuickBooks system that will eventually initiate the charge, which will take place any time between today and three days from now.

Date Signed *