Your Name
First Name
Last Name
Your Email
Your Phone
(###)
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Are you the one needing care?
If no to the question above, what is your relationship to the client?
Client Name
First Name
Last Name
Client Phone
(###)
###
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Client Email
Client Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Client Date of Birth
MM
DD
YYYY
Client Age
Client Gender
How did you hear about Metta Integrative Health
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
(###)
###
####
Date Symptoms Began
MM
DD
YYYY
Please briefly list what you are experiencing.
Are there any pre-existing Conditions?
Have you received the Covid-19 Vaccine?
Have you been tested for Covid-19?
Have you used homeopathy before
Have you worked with a Homeopathic Practitioner before
Homeopathic Remedies you've taken recently for this acute condition
Are You Currently Under the Care of a Physician(s)?
Medications you are currently taking for chronic conditions
I acknowledge that all personal information disclosed will be kept confidential. This information will not be revealed to anyone without written permission, except when disclosure is required by law. (Disclosure may be required in circumstances such as: a reasonable suspicion of child or elder abuse or a reasonable suspicion that a client presents a danger to him/herself or others.)
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I authorize discussion of my case notes with other homeopaths and/or health care practitioners should assistance in remedy selection or case analysis be necessary (for me or my child) or if my best interest is served by such consultation. Additionally , I consent to have the anonymized clinical information from my case used for case studies. I understand that my right to privacy will be protected by withholding my name and all other identifying information.
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I understand that an initial payment of $75 ($60 for current clients) is due at the time of booking my acute appointment. I understand that acute care packages are charged at a 3-day rate ($75 / $60 for current clients) OR for a 1-week rate ($100 / $80 for current clients). It is understood that acute care services beyond one week in duration will be charged a daily rate of $25 ($20 for current clients). I also understand that a transaction processing fee of 3% will be added to all domestic transactions and a 5% fee will be added to international transactions.
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I am over 18 years of age and have voluntarily chosen homeopathic treatment for myself / my child. I understand that Kirsten McGregor is a homeopathic practitioner of classical homeopathy and not a licensed medical doctor. It is, therefore, recommended that I retain the services of my primary physician for appropriate evaluations and checkups for myself / my child. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. I further understand that Kirsten McGregor does not diagnose, treat or prescribe for any particular symptoms, diseases or conditions. In consulting with Kirsten Mcgregor, I am exercising my right to choose an alternative method of treatment through which to address my total health. In signing below, I confirm that this e-signature is a legally-binding true signature.
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Date of Signature
*
MM
DD
YYYY
Your Acute Intake form was was received! Kirsten will contact you directly via email with available appointment times.
Note: If this is an emergency or a serious condition please contact your primary care provider or emergency care.
If you do not receive a response from her within 24 hours please contact her directly at kirsten@mettaintegrativehealth.com
