Client Forms

Fill out the form details below and submit before our appointment OR click the link below to download a PDF document if you prefer to print and fill out the information. For PDF downloads, once you fill in the information, please scan and send back to me via email at remedyyourhealth@gmail.com.

DOWNLOAD FORMS

PERSONAL INFORMATION

First name

Last name

Birthday

Month

Day

Year

Sex:

Male

Female

Marital Status:

Single

Married

Divorced

Widowed

Occupation

CONTACT INFORMATION:

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

PRIMARY CARE PHYSICIAN INFO:

Physician Name:

Contact Number:

HEALTH HISTORY

Please list all medications you are currently taking, including birth control and any supplements.

Please list any medications you have taken in the past.

Please list any present or prior illnesses, including skin conditions, asthma, neurological disorders, cancer and sexually transmitted diseases.

List any surgeries you have had in the past and hospitalizations.

I confirm that I am over 18 years of age and have voluntarily chosen homeopathic care for myself / my child. I understand that homeopaths are not medical doctors. Any decisions to reduce or change allopathic medications will me made with my medical doctor

Date of signature: