Reflections Homeopathy

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Consent Form

Consent Form

Please read and fill out this form carefully to give consent. If you have any trouble with the form below, you can download a copy of the consent form here. Fields with a "*" are required. You may also review our Terms of Service (link loads in another tab).

First Name*

Full Name*

Home or Cell Number*

Work Number

E-mail Address*

Physical Address

(Please provide Street, City, Province/State, Country, Postal Code)

Date of Birth*

Age (5-90)

Occupation

Hours Worked (40 maximum)

If child, name of Parent or Gaurdian

Referred by

Physician Name and Phone Number

By providing my initials, I understand that Tina Spathis is a professional homeopath trained in the classical tradition, and is not a licensed medical doctor. As such, I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions. In consulting with a professional homeopath I am exercising my right to choose an alternative method of treatment through which to address my total health. As homeopathy is not covered by the existing medical insurance plan, I agree to pay all fees at the time service is rendered payable by cash or cheque, as well as charges incurred for missed or cancelled appointments without sufficient notice (24 hours notice).

Initials