Your Name
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First Name
Last Name
Your Email
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Your Phone
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(###)
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Are you the one needing care?
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If no to the above, what is your relationship to the client?
Client Name
First Name
Last Name
Date of Birth
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MM
DD
YYYY
Age
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Gender
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Occupation
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Best Phone for Contact
If different from above phone
(###)
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How did you hear about Metta Integrative Health
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
(###)
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Primary Health Concerns in Order of Importance (since when have they occurred?)Â
Select the following conditions you have had:
Other Major Conditions Not Listed:
Are You Currently Under the Care of a Physician(s)?
Any Major Surgeries / Hospitalizations?
Any Accidents / Traumatic Injuries / Broken Bones?
Any Environmental or Food Allergies?
Are there any of the preceding conditions after which you have not been totally well again? Which ones?
Medications you are currently taking (and any adverse effects)
Vitamin / Mineral Supplements you are currently taking
What Other Therapies or Healing Modalities Are You Currently Following?
Have you used homeopathy before
Have you worked with a Homeopathic Practitioner before
Homeopathic Remedies you've taken in the last 2 months
Have you received the Covid-19 Vaccine?
Did you experience any negative effects Post-Vaccine?
Menses / Menopause
Pregnancies
Check all that apply:
Addition Comments
Check all that apply:
Additional Comments
Nutrition
Food Cravings
Exercise
Stress
Healthy Relationships
Unhealthy Relationships
Intimacy
Spiritual Life
Hobbies & Creative Expression
Refined Sugars
Tobacco
Alcohol
Caffeine
Recreational Drugs
Personal Life
Family Life
Social Life
Work Life
Sex Life
Mother
Father
Brothers
Sisters
Children
Which of the following ailments, or any other major ailments, have affected your relatives:
Including immediate and extended family i.e Grandparents, Aunts, Uncles
Is there anything else you would like to comment on?
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 full payment is due 48 hours prior to my appointment time. Additionally, I understand that cancellations must be made (at the very latest) 48 hours prior to my scheduled appointment. I acknowledge that if I fail to do so I will be charged the full fee of the consultation. I also understand that a transaction processing fee of 3% will be added to all domestic transactions and 5% will be added to all international transactions.
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I understand that during my chronic care treatment I may require acute homeopathic care. I understand as a current chronic care client I am extended a 20% discount for all acute care services. 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
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MM
DD
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