Consent Form | Inner Sea Homeopathy

Name (required)

Full Name

Name of Minor (if Applicable)

Date of Birth (required)

Email (required)

Phone (required)

Street (Mailing Address for Remedies)

City

State

Zip

Date of Onset

Chief Complaint

Current Treatments

Are you currently receiving medical or therapeutic care, on any medications, taking supplements, or scheduled for any surgeries?

Medical History

It is helpful to have a timeline of injuries, illness, and interventions that you have experienced. Please list those below. The following questions are relevant:
• That you are aware of, did you experience any birth trauma?
• Were you vaccinated or medicated as a child? Did you have any surgeries?
• Did you have any head injuries, even concussions or falls?
• Any car accidents?
• Any major dental work?
• Were you ever hospitalized?

Family Health History

The health of your parents and family members is also important. Please share any available information regarding the following:
• Your mother’s pregnancy with you
• Any illnesses or traumas experienced by parents, siblings or other relatives

Additional Information

Anything else that you feel is important can go below. We will discuss your health on a deep level, so use this for a brief outline of additional topics and we will be sure to cover these in our consultation.

Preferred Payment Method

Credit / Debit Card

Cash

Bitcoin

Check

Gold or Silver

Venmo

Zelle

What is your preferred method of payment? We accept Zelle, Venmo, Credit Cards online, as well as Cash, Check, Gold, Silver, and BTC by arrangement.

How did you hear about us? (required)

Consent (required)

I am over 18 years of age and have voluntarily chosen homeopathic treatment for myself or my child.
Homeopathic treatment considers the whole individual in developing a care protocol. The goal of homeopathic care is to enhance your or your child’s core vitality and strength. The mental and emotional symptoms of the client are as important as the physical symptoms. During your consultations, discussion will cover your entire symptomatology in light of your unique circumstances. We ask that you consent to the following prior to treatment: • Sarah Thompson is not a medical doctor. Sarah does not diagnose, treat, or prescribe for any particular symptom, disease, or condition, and nothing said in consultation should be interpreted as medical advice. I will retain a primary care physician as needed. • I understand that a minor aggravation of symptoms may occur as deeper healing takes place, and is a desirable part of the healing process. • I understand that all information disclosed during a consultation is confidential. o Nothing will be revealed without written permission, except where required by law. o I authorize discussion of my case notes or my child’s case notes with other homeopaths; notes will be anonymized to preserve privacy.

Consent for Homeopathic Care

Thank you!

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