Confidential Intake Form (Homeopathy)

Date____________________

Name__________________________________________________________________________

Street Address___________________________________________________________________

Mailing Address__________________________________________________________________

Email Address______________________________          Cell #_____________________________

Home #_____________________________                         Work #____________________________

Date of Birth______________________                Height_____________  Weight_____________

Occupation(s)_____________________________________________________________________

Emergency Contact Name________________________________  #__________________________

Primary Care Physician:______________________________________________________________

Other Health Care Providers___________________________________________________________

Goals of Treatment __________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Chief Complaints _____________________________________________________________________

___________________________________________________________________________________

Medical Conditions/Diagnoses __________________________________________________________

___________________________________________________________________________________

Medications/Supplements _____________________________________________________________

____________________________________________________________________________________

Other Concerns: ______________________________________________________________________

____________________________________________________________________________________

CONSENT, DISCLOSURE AND DISCLAIMER:

I understand that if I need medical treatment, I will seek it from a qualified medical professional.  ______ (Please initial.)

I consent for the following:

You contacting me by phone        Yes / No

You contacting me by text            Yes / No

You contacting me by e-mail        Yes / No 

You contacting me by Zoom         Yes / No

You contacting me by Face Time   Yes / No

You may withdraw your consent at any time in writing, by e-mail, text, letter or phone call.

 

Signed ……………………………………………………………………………………

 

Date ………………………………………………………………………………………