• Family Homeoprophylaxis Intake

    Share your household details and health history for homeopathic prophylaxis, including separate pages for each child.

  • Family Information

  • Format: (000) 000-0000.
  • Who is included in this intake*

  • Adult Intake — Mother/Adult 1

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Any significant reactions to vaccinations, medications, illnesses, or medical treatments?
  • Previous homeopathic prophylaxis?
  • Common Illness Symptoms
  • Illness Onset Pattern

  • Adult Intake — Father/Adult 2

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Any significant reactions to vaccinations, medications, illnesses, or medical treatments?
  • Previous homeopathic prophylaxis?
  • Common Illness Symptoms
  • Illness Onset Pattern

  • Child Intake — Child 1

    Complete this section for the first selected child.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Birth history
  • Child feeding history
  • Please indicate if your child has been exposed to or contracted any of the following diseases

  • Health Profile Conditions

  • Please indicate if your child experiences any of the following, how often, and what degree of intensity. Indicate Current or Past
    Rows
  • Please indicate if your child experiences any of the following learning disorders
    Rows

  • Child Intake — Child 2

    Complete this section for the second selected child.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Birth history
  • Child feeding history
  • Please indicate if your child has been exposed to or contracted any of the following diseases

  • Health Profile Conditions

  • Please indicate if your child experiences any of the following, how often, and what degree of intensity. Indicate Current or Past
    Rows
  • Please indicate if your child experiences any of the following learning disorders
    Rows

  • Registration and Consent for FHCi HPx Programs

    Memorandum of Understanding

  • I understand that Amber Bees Lombard, is the HPx Practitioner for the administration of this program. I understand that she/he is/ is not a medical doctor. However, she offers Homeoprophylaxis in accordance with the state provincial law in Texas. She is offering to me HPx Programs as outlined by Free and Healthy Children International (FHCi). And she is an agent of FHCi for the administration of the HPX program and will serve to be my direct point of contact for any questions regarding the administration of the program or response that may occur. 

    I understand that I can withdraw from this agreement at any time.

    Payment of the program costs and delivery of these signed documents to an HPx Practitioner is considered sufficient for my one-time registration for the duration of participation of the select HPx Program as outlined by FHCi. Term begins with the date of submission of this contract.

     

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