GENERAL CONSENT FORM FOR HOMEOPATHIC TREATMENT 

Homeopathy and other holistic methodologies view health and illness from a different perspective than the standard, conventional medical approach, which limits its concerns to individual symptoms. The homeopathic interview takes the whole person into consideration, and regards the spiritual, mental and emotional symptoms as important as the physical aspects.

~I understand that a minor aggravation or worsening of some symptoms may occur temporarily as part of the healing process.

~I understand that all information disclosed to the practitioner during the homeopathic consultation is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law.

~I authorize discussion of my case notes with other professional homeopaths if my (or my child’s) best interests will be served by such a consultation. My right to privacy will be protected by withholding my name and any other identifying information.

~I am over 18 years of age and have voluntarily chosen homeopathic treatment for myself / my child. I understand that Nancy Frederick is a homeopath and not a medical doctor, and does not diagnose, treat or prescribe for any particular symptom, disease, or condition. It is therefore recommended that I retain the services of a primary care physician for appropriate evaluations and check-ups. I understand that the goal of homeopathy is to increase my / my child’s general vitality and constitutional strength.

Patient Name……………………………………………………………………………….

Date of birth………………………………………………………….Time……………….

If child, parents’ names…………………………………………………………………….

Mailing Address……………………………………………………………………………

                             …………………………………………………………………………….

Telephone…………………………………………………………………………………..

E-mail……………………………………………………………………………………… 

Referred by…………………………………………………………………………………

Signature…………………………………………………………………………………...                 Date..........................................................