Acute Condition Appointment Request
Acute conditions are ones you've had under 4 weeks. This form is to be filled out by an adult who is at least 18 years old. Also, please understand that when healing with homeopathy, there’s always a bell curve to the process. Can you picture a bell? Homeopathy moves your body through the process faster so that resolution is expressive, not suppressive. Suppressing acute conditions leads to future chronic conditions. Homeopathy isn’t magic. It’s a natural system of medicine. You’re going to go through the process at a faster rate with homeopathy without causing future harm.
This is 5 days of TEXT support. Not a phone call or appointment
You will be working with Melissa or one of her associates that she has personally trained.
This form is for ONE person only
You will need to submit separate forms for each person that is sick.
NOTE 1:
You’re going to need homeopathic remedies so if you don’t own a kit, you’ll need to go buy them or order them. SKIN CONDITIONS ARE NOT LIKELY TO GET BETTER IN 5 DAYS EVEN IF THEY'RE NEW.
NOTE 2:
SKIN CONDITIONS ARE NOT LIKELY TO GET BETTER IN 5 DAYS EVEN IF THEY'RE NEW. Do not complete this form for skin conditions other than bites and stings.
NOTE 3:
If you have not heard from someone within a few hours, please text Melissa at 704-918-8214.
Who is the request for?
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First Name
Last Name
Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
What is your Time Zone?
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Today's Date
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Month
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Day
Year
Date
Birthdate
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Month
-
Day
Year
Date
Are you a current client in my chronic clinic?
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Yes
No
What is the chief complaint? What other symptoms are presenting with it?
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Timing: When did these symptoms first appear?
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On a scale of 1-10 where 1 is mild and 10 is severe, how would you rate each symptom?
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What homeopathic remedies have you tried for THIS condition? List potencies and frequencies too.
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Consents
Type your full name under each consent if you agree.
I understand that I will need to purchase homeopathic medicines in order to follow the plan. I also understand that Homeopathy is not designed to shut down the process, rather help me move through the process faster.
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First Name
Last Name
I am at least 18 years old and if this form is for a child, I am the legal guardian of the child listed on this form.
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First Name
Last Name
I understand that if I or my child has a life-threatening condition, I will seek immediate medical attention for me/him/her and I will always seek the advice of a licensed healthcare practitioner when I need it.
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First Name
Last Name
I understand that healing with Homeopathy is a process that is expressive; not suppressive.
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First Name
Last Name
I understand that I will be working with Melissa OR one of her associates that she has personally trained. Melissa will assign my case to herself or one of her associates.
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First Name
Last Name
I understand that all fees are nonrefundable
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First Name
Last Name
I understand that my relationship with Melissa and her associates is not that of a patient and doctor, but it is a relationship of educator and student. I am the student and she is the homeopathic educator. I agree, by typing my full name here, that anything I use in her homeopathic care plan is my choice and at my discretion.
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First Name
Last Name
I understand that Melissa or her associate will respond to text messages between 9am and 4pm ET Mon-Sat only.
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First Name
Last Name
If someone referred you to me, please type their name here.
I actually READ all of this information
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Type your name or initials
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Medical Diagnoses
This section helps me in remedy selection. Please answer thoroughly.
By signing this form I agree that everything here is true to the best of my knowledge and I give Melissa permission to teach me how to use homeopathy.
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Add a photo of skin conditions and wounds if desired
My Products
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( X )
Acute Consultation
$
75.00
You are paying for an acute consultation with me for an acute condition. You will get 5 days of text support.
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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