Appointment Request
This form is provided for you to request a free 15-minute phone call in order to ask questions and find out how we work our consults.
You will receive a text message
Within 7-10 business days, you will receive a text message during normal business hours.
You will get an email
After your phone call, you will receive an email with the link to schedule your initial consultation.
Submissions
After you click submit, you should receive a confirmation email. If you do not receive that, your form did not go through and you will need to resubmit it.
Who are you seeking care for?
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First Name
Last Name
Is this for yourself or a family member?
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Type "myself" or "my son" or "my daughter," etcetera
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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We will try to text you during regular business hours according to your time zone.
Today's Date
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-
Month
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Day
Year
Date
Birthdate
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-
Month
-
Day
Year
Date
How did you hear about me?
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Name of person or business
Do you have a family member in my chronic clinic?
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Yes
No
What is the chief complaint?
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0/100
How long have you had these conditions?
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0/50
Have you used homeopathy before?
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0/25
Are you currently working with a homeopath?
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0/25
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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.
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First Name
Last Name
I understand that submitting this form does NOT automatically approve me for an initial consultation.
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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 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 they are the homeopathic educators. I agree, by typing my full name here, that anything I use in their homeopathic care plan is my choice and at my discretion.
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First Name
Last Name
If someone referred you to me, please type their name here.
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By signing this form I agree that everything here is true to the best of my knowledge and I give Melissa and her associates permission to teach me how to use homeopathy.
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Practitioner Notes
Do not type in this box
Submit
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