Pre-Informed Consent & Intake Form

All recommendations made by the homeopathic practitioner are based on the principles of homeopathy and are not replacements for 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 caregivers 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 to me the nature and purpose of the homeopathic regimen in general and my care in particular.

I further acknowledge and confirm that I have been made aware of homeopathy and the basic principles of homeopathy, the nature of homeopathic care for 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 the 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.