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Your Information

Your Name

First Name *

Last Name *

Email Address *

Are you the one needing care? - Adults (or parent if a minor) must sign consent form below *
Yes
No

Client Phone Number *

Client Address

Street Address *

Address Line 2

City *

State/Province/Region *

ZIP/Postal Code *

Country *

Client Date of Birth *

Client Gender *
Male
Female

Preferred Method of Client Communication
Online Video Conference
Phone Call

How did you hear about us?

Are you or your family currently working with us?
Yes
No

Is the client an existing or a new chronic client? *
Existing Client
New Client

Health Information

Date Symptoms Began *

Please briefly list what you are experiencing *

Pre-existing Conditions *

Current or Recent Medications & Labwork *

Is the client familiar with homeopathy?
Yes
No

Does the client already work with a homeopath? *
Yes
No

Does the client have access to homeopathic remedies at home or locally? *
Yes
No

Agreement for Consultation

Consent *

I verify that I have read and understand the terms of service outlined above and hereby give my consent for care.