Print & Mail / Fax Coaching/Consult Order Form
Print ... fill out ... and mail or fax this form with your payment.
(US dollars only, please, for checks/money orders.)

For secure online ordering with major credit/debit card or PayPal, click here.

[ Back to main site: ]

Private Consultation/Coaching with Dr. Alexandra Gayek

Description Item # Quantity Price Each Total
Single consult/coaching session (50 min.) C1 $150 US $__________
Extended single consult/coaching session (up to 90min.) C2 _______ $195 US $__________
Coaching super session (up to 2 hours) C3 _______ $245 US $__________
For FASTEST DELIVERY, we're happy to take your credit/debit card or PayPal order on our secure server at
TOTAL Enclosed (US Funds) $__________

Please PRINT clearly!
Payment Information (Make Payment in US Dollars ONLY)
(Cardholder) Name: Email:
(Billing) Address:  
City & State/Province/Other:
Phone: Zip/Postal Code: Country:
Credit/Debit Card Account No.: Expires:
(Cardholder) Signature: Thanks for your order!
__VISA __MasterCard | __Check __Money Order
payable to Dr. Alexandra Gayek

Mail or FAX this completed form with payment to:

Dr. Alexandra Gayek
PO Box 522
Olga, WA 98279
FAX TO: 206.260.2432

Back to Main Site     |     ©2005 Dr. Alexandra Gayek