Pre Informed Consent & Intake Form

If you are about to make your first appointment with us, please take a moment to fill out the below intake form.

We encourage you to complete the consent and Intake form prior to your appointment. Please contact us for any clarification or to see if your health condition needs a more specific health questionnaire.

Pre-Informed Consent & Intake Form

Please consent to the following information and also fill in the details to enable us to review your case.

Pre Informed Consent(Required)

All recommendations made by the homeopathic practitioner are based on the principles of homeopathy and not replacements to any medical regimens or treatments prescribed by one’s medical doctor or any other licensed care provider.

The course of action one takes with his or her health care is solely the responsibility of the individual.

Homeopathic care consists of homeopathic consultation and prescription of homeopathic remedy with required dosage, mode of taking and diet / regimen required with it. It is recommended that the person communicates openly with all of his or her medical doctors or licensed care givers about any prescription by the homeopathic practitioner.

At no time can the homeopathic practitioner guarantee the outcome of the homeopathic consultation, prescription, and care. One must be aware that the outcome and duration of homeopathic care vary by individual and cannot be guaranteed. We do not claim to cure each and every case, nor do we guarantee any magic cure.

I, the undersigned, do understand that the practitioner will explain me the nature and purpose of homeopathic regimen in general and my care in particular.

I further acknowledge and confirm that I have been made aware about homeopathy and basic principles of homeopathy, the nature of homeopathic care acute and chronic illnesses, prognosis, expectations, nature and safety of remedies / products and fee schedule and all the information I provide is confidential and who will have access to it. I’m also aware of the possibility of follow-up visits.

I understand that I can withdraw my consent at any time.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or when law requires it.

I understand that I may look at my record at any time and can request a copy of it or have a report drawn up by paying the appropriate fee. I understand that information from my medical record may be analyzed for research purposes and that my identity will be protected and kept confidential.

As a result, I do hereby voluntarily provide my informed consent for the recommended care specified above.

I consent to the homeopathic care offered or recommended to me by my homeopath. I intend this consent to apply to all my present and future homeopathic consultations.

Name(Required)

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Intake Form

Address(Required)

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Email(Required)

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Phone(Required)

Emergency Contact Number(Required)

Age(Required)

Date of Birth(Required)

Gender(Required)

Parent's Name(Required)

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Chief Complaint(Required)

List Current Medication & Supplements (& since when?)(Required)

Pre existing illness or Allergies(Required)

Any adverse effects from vaccinations?

Please Specify

Number of Pregnancies

Number of Children

Have you gained or lost weight recently?

Any Surgeries, Complication or Injuries?

Do you consume any of the following substances?

Coffee / Tea

Alcohol

Tobacco

Recreational Drugs

Mother's pregnancy history?(Required)

Family history of any illness?(Required)

Are you registered with a family doctor?(Required)

Family Doctor's name(Required)

Any previous Homeopathic remedies / products used?(Required)

Do you have recent lab reports that you wish to share?

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