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. This form is NOT for Acute Care Consultations.
You will receive a text message
Within 3 business days, you will receive a text message during normal business hours. If you do NOT hear from Melissa within 3 business days, please text her at 704-918-8214.
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. If you still do not receive a confirmation email, please text Melissa at 704-918-8214.
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
-
Day
Year
Date
Birthdate of person needing care
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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
Select your interests
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Homeopathy
Phototherapy
BOTH
Have you used homeopathy before?
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0/25
Do you have a preference on who you work with? Select all that apply.
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Melissa
Bri
Kimberly
Abby
Anybody is fine
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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