CONSULTATION REQUEST The Consultation Session that will be conducted by Dr. Andrew Kaufman is for informational/educational purposes only and shall NOT be construed as medical advice. Dr. Kaufman voluntarily and intentionally let his medical license expire in 2020. He is no longer a Licensed Physician and this Consultation Service shall NOT BE construed as the practice of Medicine. This information is for you to use as you see fit. There is NO guarantee of your outcome based upon how you use this information. The information provided is the best information available given what is known at the time of the consultation. The outcome of using this information is based upon many factors, such as your dedication, responsibility for your own well-being, attention to detail, etc. No warranty is expressed nor implied. You assume all risk and responsibility for using this information. Financial Responsibility You understand and accept the payment terms as discussed with Dr. Kaufman. You understand that payment is required in advance of the consultation. You certify that payment for these services will not place an undue financial burden upon you. All payments are non-refundable. Agreement to Contract and Consent for Consultation* Yes. I agree to contract and consent with all the terms of service as stated in the "Consent for Consultation" presented to me. Type of Consultation ServiceWhich Consultation Service are you Requesting?*-Please Select-Natural Healing ConsultationHealth AdvocacyCancer AdvocacyCurriculum DevelopmentProfessional MentoringBusiness ConsultingMedical Science ConsultationIs this a Follow-up Appointment to a Previous Consultation Session?*-Please Select-NoYesA Follow-up Appointment is deemed one that follows a previous session that took place within 90 days. If you have not had a Consultation Session in the last 90 Days, then select "No". Basic Contact DetailsName* First Last Email* Phone*Which Time Zone are you Currently Located?*-Please Select-GMT Greenwich Mean Time GMTUTC Universal Coordinated Time GMTECT European Central Time GMT+1:00EET Eastern European Time GMT+2:00ART (Arabic) Egypt Standard Time GMT+2:00EAT Eastern African Time GMT+3:00MET Middle East Time GMT+3:30NET Near East Time GMT+4:00PLT Pakistan Lahore Time GMT+5:00IST India Standard Time GMT+5:30BST Bangladesh Standard Time GMT+6:00VST Vietnam Standard Time GMT+7:00CTT China Taiwan Time GMT+8:00JST Japan Standard Time GMT+9:00ACT Australia Central Time GMT+9:30AET Australia Eastern Time GMT+10:00SST Solomon Standard Time GMT+11:00NST New Zealand Standard Time GMT+12:00MIT Midway Islands Time GMT-11:00HST Hawaii Standard Time GMT-10:00AST Alaska Standard Time GMT-9:00PST Pacific Standard Time GMT-8:00PNT Phoenix Standard Time GMT-7:00MST Mountain Standard Time GMT-7:00CST Central Standard Time GMT-6:00EST Eastern Standard Time GMT-5:00IET Indiana Eastern Standard Time GMT-5:00PRT Puerto Rico and US Virgin Islands Time GMT-4:00CNT Canada Newfoundland Time GMT-3:30AGT Argentina Standard Time GMT-3:00BET Brazil Eastern Time GMT-3:00CAT Central African Time GMT-1:00 Preferred Session DurationQuestions are intended to pinpoint the issues you intend to discuss during the session. All questions may or may not be covered.Choose Your Preferred Session Duration* 30 Minutes - $200 60 Minutes - $400 90 Minutes - $600 120 Minutes - $800 Choose Your Preferred Session Duration* 60 Minutes - $400 90 Minutes - $600 120 Minutes - $800 Questions for Dr. AndyQuestion 1* Please keep your question precise and concise.Question 2 Please keep your question precise and concise. Upload Documents for Dr. AndyDo you have any documentation that that you need Dr. Andy to consult during the Consultation?-Please Select-NoYesUpload Documents* Drop files here or Select files Max. file size: 20 MB. If you feel you have any important documents relevant to your Consultation, please upload them here. Andrew Kaufman, M.D. True Healing | Medicamentum Authentica 541 Allen Street Syracuse, NY 13210 CONSENT FOR CONSULTATION This consultation is for informational purposes only and shall not be construed as medical advice. Although Dr. Kaufman is a licensed physician, this consultation service shall not be construed as the practice of medicine. This consultation is for educational purposes only. This information is for you to use as you see fit. There is no guarantee of your outcome based upon how you use this information. The information provided is the best information available given what is known at the time of consultation. The outcome of using this information is based upon many factors, such as your dedication, responsibility for your own wellbeing, attention to detail, etc. No warranty is expressed nor implied. You assume all risk and responsibility for using this information. FINANCIAL RESPONSIBILITY You understand and accept the payment terms as discussed with Dr. Kaufman. You understand that payment is required in advance of the consultation. You certify that payment for these services will not place an undue financial burden upon you. All payments are non-refundable. By signing below, I agree with all the terms of service as written above. Eligibility to Consent* I am over the age of 18 Years and am eligible to consent for myself. I am under the age of 18 Years and/or require a Parent/Guardian to consent for me. I am Consenting on behalf of another and am authroised to do so. Please choose which of the following statements applies to you.What is the age of the person who is the subject of the Consultation?* Date* MM slash DD slash YYYY Signature*Print Name* Parent/GuardianDate* MM slash DD slash YYYY Signature of Parent/Guardian*Print Name of Parent/Guardian* CommentsThis field is for validation purposes and should be left unchanged.