female-homeopathy - Alt Therapies Center

Case History Information

Name:

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Your Doctor’s Name:

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Consent for Homeopathic Treatment and Care

I, the undersigned, do hereby request and consent for the homeopathic treatment. I have been informed that homeopathic remedies are safe, but occasionally there may be aggravation of the symptoms just for few hours.

I wish to rely on the homeopathic practitioner to exercise judgment during the course of the treatment, which the practitioner feels at the time, is in my best interests.

By signing below, I agree to the above-named therapy. I intend this consent to cover the entire course of treatment for my present condition(s).

Patient’s Signature:

Date:

Alt Therapies Center
Sucheta Dagli Shah LAC, MSOM

Homeopathy Female Form

Case History Information

Consent for Homeopathic Treatment and Care

Case History Information

Please List Current Medications:

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