Child Intake Form - Serenity Homeopathic Clinic

Step 1 of 7

Emergency Contact Information
Parent #1 Name*
First Last
Parent #2 Name
First Last
Parent #1 Occupation*
Parent #2 Occupation
Parent #1 Primary Phone*
Parent #2 Primary Phone
Parent #1 Secondary Phone
Parent #2 Secondary Phone
Parent #1 Email*
Parent #2 Email
Doctors Information
Name
First Last
Phone
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Are You Seeing Any Other Complimentary Or Alternative Health Care Practitioners?*
- No
- Yes
Name
First Last
Occupation
Name
First Last
Occupation
Referred By:
How Did You Find Lucy?*
Which Website?
Name Of Friend
First Last

Informed Consent To Homeopathic Care
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).
Fees
Adults

Initial homeopathic consultation (2 hours) - $200

Follow-ups (40 - 60 minutes) - $95

Remedy - $17

Seniors 60 and over, Children 12 and under

Initial homeopathic consultation (2 hours) - $170

Follow-ups (40 - 60 minutes) - $75

Remedy - $17

10 minute contact between appointments are free of charge, but if a condition arises when a different remedy is needed, it will be treated as an acute appointment.

Acute care from - $50
GST now applicable at 5% All fees are payable at the end of the consultation.

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 Questionnair
Name*
First Last
Date*
Today's Date
By Checking 'Yes' You Are Agreeing To The Terms Above (This Is The Digital Form Of A Signature)*
- Yes
- No

Confirmation
Child Name*
First Last
Parent Or Legal Guardians Name*
First Last
Date Signed*
Todays Date
By Checking 'Yes' You Are Agreeing To The Terms Above And That All Information Is Accurate (This Is The Digital Form Of A Signature)*
- Yes
- No
This information is strictly confidential.
Thank you, for your cooperation in completing this form.
Medical Files
Please Upload Any Medical Files Related To The Condition To Be Treated (ie: blood tests, naturopathic tests, official diagnosis documents, etc)
Drop files here or

Max. file size: 256 MB.
Just A Security Measure
Please confirm you are human.

Step 1 of 7

REGISTRATION FORM FOR CHILDREN 12 AND UNDER

Personal Information

Emergency Contact Information

Doctors Information

Referred By:

Informed Consent To Homeopathic Care

Fees

Adults

Seniors 60 and over, Children 12 and under

Confidential Information
Personal Medical Questionnair

Personal Health

Family Health

Pregnancy

Confirmation

Step 1 of 7

REGISTRATION FORM FOR CHILDREN 12 AND UNDER

Personal Information

Emergency Contact Information

Doctors Information

Referred By:

Informed Consent To Homeopathic Care

Fees

Adults

Seniors 60 and over, Children 12 and under

Confidential Information Personal Medical Questionnair

Personal Health

Family Health

Pregnancy

Confirmation

Confidential Information
Personal Medical Questionnair