Patient Intake Form

The online intake form consists of:
1) personal case history, 2) legal consent form, 3) privacy documents and 4) medical disclaimer.

Click here to fill out the online Patient Intake Form

The first section of the form pertains to your personal, medical case history and is followed by a legally required, informed consent form. By reading the other sections of this website and then submitting this form you indicate that you understand and have been provided with procedural and fee information sufficient to permit you to make a knowledgeable decision whether to proceed with this type of care. Understanding that doctors are forbidden to guarantee health outcomes, acceptance of your case for care from this office will imply that you can reasonably expect the benefits of partially or completely improved health through the sole application of homeopathic medicines which are well known to pose no danger. Not having these procedures may leave you in your present, or a worsened state of health as time progresses unless referred for other care. The options for this alternate action should be discussed individually. The final section of the form allows you to acknowledge, as well, how this office adheres to the federal requirements of the Privacy Act. Final acknowledgement is then needed for the Disclaimer which describes the scope of a doctor's obligations. This online form must be filled out and submitted before diagnostics and treatment can begin. Evaluation of this data will determine whether alternative care from this office can be helpful. Consequently, a case will be accepted for treatment which is conducted on a trial basis pending observed improvement, or referred elsewhere for more appropriate care.