Vigilant Society

On-line Request and Payment Form

20 Minutes +/- Talk Time* - $50.00 Per Call!

*First Name:

*Last Name:

*Address:

Apt #:

*Zip Code:

*City:

*State:

*Country:

*Phone:

-
Home Business Cell

*Preferred Language:

*E-mail Address:

Best Time For Doctor To Call:

AM(0600-1100 hrs) PM(1800-2300 hrs) (Important - non Emergency)

*Medical Specialty of interest:

Subject of Medical Concern:

I agree with Terms and Conditions & Privacy Policy & Arbitration Agreement

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From the Director of Talk To A Doctor Program: Vigilant Society Values Your Privacy
Your information will only be used by Vigilant Society. We do not and will not sell your information to any other party. By giving us your phone number, you are granting us permission for the possible use of prerecorded/artificial voice or text messages and/or automated dialing systems to contact you or deliver your requested information, as the law allows. And you agree that we may use any telephone number you provide, even if it is a mobile telephone number that may result in charges to you.

NOTICE! PLEASE READ THIS NOTICE! Talk Time is intended to be fully 20 minutes from time call is placed by a Vigilant Society Doctor. In such eventuality or circumstance that the line is disconnected or connection broken the Vigilant Doctor will again redial your number (1) time only, at the number you already provided, to complete the full 20 minutes of discussion. All Talk To A Doctor calls are subject to being slightly more or less and may be imprecise in the exactness of time. In all cases a call being made to you, being answered by any source whether live or mechanized during the time specified plus or minus 1 hour whether AM or PM shall be considered a completed call and all obligations by the Vigilant Doctor will have been completed. NOTE: Refund Policy: Generally No Refunds Shall Be Provided At Anytime For Any Reason! You aare invited to address your comments or complaints providing he details of your request to: Refund Committee and sent to: info@vigilantsociety.com Note: Each comment and / or complaint will be addressed and appropriate action taken. Where a complaint is made a review will be made with the physician, the physicians recommendation shall always prevail. If the complainant is remotely justified in his position, Vigilant Society will cheerfully make refund in its entirety. We hope you understand that this is the only fair method of providing this rare real time life line service!

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VIGILANT SOCIETY'S

TALK TO A DOCTOR PROGRAM