REGISTRATION FORM FOR ADULTS

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I hereby request and consent to the performance of homeopathic treatment.

I understand that Lucy De Pieri is a trained classical homeopath and not a licensed medical doctor.

I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions.

I understand that, as in all health care, in the practice of homeopathy there are some very slight risks to treatment, including, but not limited to, aggravation of complaints.

Homeopathy is not covered by the existing government medical insurance plan, but it is included in some extended medical insurance. I agree to pay all fees of the consultation and any remedies as prescribed.

I have read the above consent. I have also had the opportunity to ask questions about its content and my case. I intend this consent form to cover the entire course of treatment for my present condition(s) and future condition(s).

Acute care from - $50

Appointments - If you have to reschedule or cancel your appointment time, please give me at least 25 hours or the fees will be charged in full. Thank you.

Accepted form of payment - Cash, cheques (payable to Serenity Homeopathic Clinic), Internet e-transfer and credit cards.

Confidential Information

Personal Medical Questionnaire

This information is strictly confidential.
Thank you, for your cooperation in completing this form.