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.
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
Today's Date
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Month
-
Day
Year
Date
Birthdate
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Month
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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.
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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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