Print & Mail / Fax Coaching/Consult Order FormPrint ... 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: www.scienceofbeingwell.net ] 
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 | $__________ | |||
| Consult/coaching package(four 50 min. sessions) | C3 | _______ | $500 US | $__________ | |||
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| TOTAL Enclosed (US Funds) | $__________ | ||||||
| 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 |
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Mail or FAX this completed form with payment to:Dr. Alexandra Gayek2400 NW 80th Street, Box 304 Seattle, WA 98117-4449 FAX TO: 206.260.2432
Back to Main Site | ©2005 Dr. Alexandra Gayek |