Consent Form

General Consent form for homeopathic treatment

Homeopathy is a holistic medicine that treats the whole person, working to stimulate and help the body to heal itself. It utilizes dilute substances derived mainly from plant, animal, and mineral sources. For a proper homeopathic prescription, a thorough history and examination are required. Nutritional assessment and counselling are often a part of the intake process. When used correctly under the supervision of a qualified practitioner, homeopathy is considered to be a safe integrative/ preventive system of health care. It is not intended to be a substitute for allopathic medicine.

All recommendations made by the homeopathic practitioner are based on the principles of homeopathy and are not replacements for any medical regimens or treatments prescribed by one’s medical doctor or licensed care provider. The course of action one takes with his or her health care is solely the responsibility of the patient. It is recommended that the client communicates openly with all of his or her medical doctor or licensed caregiver.

I understand that minor aggravation or worsening of some symptoms may occur temporarily as a part of healing process.

At no time can the homeopathic practitioner guarantee the outcome of the homeopathic treatment. One must be aware that the outcome and duration of homeopathic treatment vary by individual and cannot be guaranteed. We do not claim to cure each and every case, nor do we guarantee any magic cure.

I, the undersigned, do hereby acknowledge that I have been informed of and understand the assessment and recommended treatment described above and have discussed to my satisfaction this and any requests for related information with the Homeopath, Kalyani Zodey MD (Hom).

I have been given the opportunity to ask questions about the assessment and recommended treatment and have received answers to such questions.

I further acknowledge and confirm that I have been informed about what is homeopathy and basic principles of homeopathy, the nature of homeopathic treatment, acute and chronic illnesses, prognosis, treatment expectations, nature and safety of medicine and fee schedule and all the information I provide is confidential and who will have access to it. The possibility of follow-up visits was also discussed.

I understand that all information disclosed to the practitioner during the homeopathic consultation is confidential and may not be revealed to anyone without written permission, except where disclosure is required by law.

I understand that I can withdraw my consent at any time.
As a result, I do hereby voluntarily provide my informed consent for the recommended treatment specified above.

I acknowledge I have discussed, or have had the opportunity to discuss, with my homeopath the nature and purpose of homeopathic treatment in general and my treatment in particular as well as the contents of this Consent.

I consent to the homeopathic treatments offered or recommended to me by my homeopath. I intend this consent to apply to all my present and future homeopathic treatments.