New Client Forms | Homeopathic Associates

Secure New Client Intake Forms

This is the first step in your journey to health & well-being! Getting sick is the easy part, but getting well takes patience & dedication to take control of your life again. We’re happy to be here to support you on this journey. If you have any problems filling out your “paperwork”, please give us a call 619-741-5795. Remember, our “doors”, er phone, is open to anyone in the world through our telephone only clinic.

Pulsatilla Pratensis Homeopathy — Pulsatilla Pratensis - Windflower

Step 1 of 4

SECURE Online Client Profile for Homeopathic Associates - Page 1
FILL OUT FOR THE PERSON TO BE TREATED. Start with the basics - such as the name, address, occupation, etc.
Name of the Person to Be Treated*
First Last
Preferred name or "nickname"

Enter the name you go by
Who is the person to be treated? (i.e. yourself, your child, your mother, etc)*
How did you hear about us?

Whom were you referred by?
Mailing Address. This is the address where your remedies will be sent.*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
Please enter the best phone number to reach you on.
Secondary Phone Number
Please enter your second best number number to reach you on.
Location (City, State, Country) & Timezone*
Look up your timezone here.
Email*
Your email address will be used for office communications only.
Date of Birth*
MM slash DD slash YYYY

Please enter the date of birth of the person to be treated
Age of the person to be treated?*
Gender*
Marital Status
Occupation
Who is the person responsible for payment of services rendered if other than the person seeking treatment?*
Relationship to the client?*
e.g. Self, Parent, Legal Guardian, etc.
Phone number of the person responsible for the account if different from above?*
Mailing Address of the Person Responsible for the Account*
Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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SECURE Online Client Profile for Homeopathic Associates - Page 2
This section is completely optional. On this page you have the option to fill out information about your health concerns. By filling it out and submitting it before your appointment, you will give us a chance to do more research into your case. You can also choose to send us this information at a later time, or you can tell us everything during your initial consultation.
What is your main health issue?
How long have you had this issue?
List any additonal health issues you have and approximately how long you have had them.
Current Medications and Supplements*
Please list all current prescription & over the counter medications, recreational drugs, nutraceuticals & supplements, homeopathics, Ayurvedic or Chinese medicines, etc, that you are taking. We use your answers to help us better understand your case. Please remember, we do not judge you on this information. We do not report it to anyone and it doesn't go into your permanent official medical records!
Other Therapies
Please list and describe any additional therapies you taking part in such as cranial sacral work, chiropractic, acupuncture, magnet therapy, far infrared saunas, zappers, ozone treatment, intravenous chelation or vitamin C, ultrasonic therapy, electro-magnetic devices and stimulators, etc.
Optional Submission of Photos, Records
THIS SECTION IS COMPLETELY OPTIONAL, BUT VERY HELPFUL TO YOUR HOMEOPATH. NOT TO WORRY, YOU CAN ALWAYS SEND US DOCUMENTS AND PHOTOS AT A LATER DATE!

Now you will have the opportunity to upload digital photos and scanned medical record summaries, reports or other write ups you feel will be helpful to your treatment. PLEASE REMEMBER, WE ONLY WANT SUMMARIES OF MEDICAL RECORDS OR PROCEDURES. WE DO NOT NEED THE ENTIRE RECORD. This knowledge may help you when asking your practitioners and clinics for copies.

Remember, if you can get copies of records at a later date, you can scan, fax or mail them to us when you are able.
SECURE UPLOAD of Photo(s) and VIdeo(s) of yourself and your health issues (optional)
Accepted file types: jpeg, jpg, gif, pdf, mov, mp3, mp4, avi, wmv, flv, Max. file size: 100 MB.
Since we have all our interactions over the phone, photos and videos help the homeopath make their assessment. However, they are not necessary to begin treatment!

PLEASE LABEL AND DATE ALL PHOTOS OR VIDEOS, or include a description in the box below. Thanks!

PHOTOS: Please upload a recent photos of yourself. It is also helpful to upload photos of yourself before & after your complaints began. If you need help with this step, please call our office at 619-741-5795.

If you have a symptom such as a skin rash, tumor, bruising, deformities or other pathology that you wish to show us, please upload the photos here as well.

VIDEOS: Videos are particularly helpful in cases of neurological conditions to show us symptoms such as tremors, gait disturbances, tics, twitches, seizures or convulsions, repetitive behaviors, etc. They are also helpful to show us tantrums, outbursts or other peculiar events.

ARE YOUR VIDEO FILES TOO LARGE? Consider first uploading your video(s) to sites like wetransfer.com, dropbox.com, google documents, youtube.com (make the video private), etc, and then sending us the link.

TIPS: If you do not have a digital photo of yourself, consider either having a friend or family member take one for you, or mailing us hard copy photos.
Medical Records or Other writes ups
Accepted file types: doc, docx, dotx, docm, rtf, pdf, xlsx, xls, xlt, Max. file size: 100 MB.
You may wish to give us copies of the SUMMARIES of your medical records or other reports about your condition. You may also wish to write up additional information to share with us. This is strictly optional. You may also choose to fax or mail the information to us at a later date.

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Online Intake Forms for Homeopathic Associates - Page 3
Please fill out the following billing information. Once we receive your information, we will call you to gather your credit/debit card information and schedule your initial appointment.
Is your credit card's billing address (where statements are sent) the same as your mailing address?*
- Yes
- No
If you answered no to the above question, please fill out the Credit or Debit Card Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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YOUR SIGNATURE AND TODAY'S DATE
Today's Date*
MM slash DD slash YYYY
Electronic Signature - please type your signature in the box below.*
Please enter the answer below:

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Secure New Client Intake Forms

Step 1 of 4

SECURE Online Client Profile for Homeopathic Associates - Page 1

SECURE Online Client Profile for Homeopathic Associates - Page 2

Optional Submission of Photos, Records

Online Intake Forms for Homeopathic Associates - Page 3

YOUR SIGNATURE AND TODAY'S DATE