Client Resources

Informed Consent

Homeopathy is a form of medicine based on the Law of Similars — that is, the use of tiny doses of the very thing that causes symptoms in healthy people. These minute doses of plant, animal, or mineral origins are used to stimulate the body's ability to heal itself. Homeopathy is a powerful tool that effects healing on a physical and emotional level

Lifestyle counselling involves identifying risk factors and making recommendations to help optimize one's physical, mental and emotional environment. 

During your initial visits, your Homeopath will take a thorough case history, and any physical examination needed. 

Please initial the following:

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others without my

consent, unless required by law. I understand that I may look at my medical record at any time and can request a copy of it by paying the appropriate fee.

I understand that the homeopath will answer any questions that I have to the

best of their ability. I understand that the results are NOT guaranteed. I do not expect the homeopath to be able to anticipate and explain all risks and complications. With this knowledge, I voluntarily consent to the procedures mentioned above, except for (please

list any exceptions):

I understand that charges are to be paid at the time of the visit unless specific arrangements have been made. (Initial Consultation $100.00) (Follow-up visits up to 45 minutes $ 50.00) Payment for all dispensary items is due at the time they are received. As the patient, you are responsible for the total charges incurred for each visit. If you have coverage for Homeopathic Medicine through an insurance company, you are responsible for billing your own insurance company.

I have read and understood the above-stated information and policies. I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw consent and to discontinue participation in these treatments at any time.

Signature of the Patient or Guardian


Homeopathy views health from a holistic perspective. Homeopaths do not make any sort of diagnosis in medical terms and it is your responsibility to maintain a relationship with a licensed physician or primary care provider for appropriate evaluations and check-ups.

***Under no circumstances should any suggestions be taken as a medical diagnosis or direction against a licensed medical or mental health care professional. *** 

By agreeing to our terms of service you agree to the following: 

  • I understand that the goal of homeopathy is to increase my or my child's general vitality and constitutional strength and that no specific disease will be diagnosed or treated.

  • I authorize discussion of my case notes with other professional Homeopa ths if my or my child’s best interests are served by such a consultation. My right to privacy will be rotected by withholding my name and any other identifying information.

  • I am over 18 years of age and have voluntarily chosen homeopathic treatment for my self/my child.

  • I am aware that that the outcome and duration of homeopathic treatment vary by individualand cannot be guaranteed. And that I as your Homeopath further offers no warranty or guarantee as to the outcome of the homeopathic treatment.

  • I agree that I have a choice with regard to where I obtain homeopathic medicines that are recommended to me or my child.

  • I waive all legal rights that may arise from the homeopathic treatment and hold the assignedHomeopath harmless from all claims, present, and future, known or unknown, in any manner arising out of the homeopathic treatment.

  • This Agreement shall be governed by the laws of the State of Pennsylvania and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the Homeopath resides.

  • The Parties agree that the terms and provisions of this Agreement embody their mutualintent and that such terms and conditions are not to be construed more liberally in favor of,or more strictly against,either Party.

  • If any provision herein is invalid, it shall be considered deleted from this Agreement and shall not invalidate the remaining provisions of this Agreement.

  • I understand that the Homeopath I will be scheduled with is not a medical doctor and does not diagnose. All recommendations are for wellness and overall health building purposes.

Patient Signature


Please take the time to be as thorough as possible filling out this form. It will help us determine the correct constitutional

homeopathic remedy for your child. Not all questions will apply to every child. Only answer those that pertain to your child


The information provided on this site is for information and educational purposes only.  Information contained should not be taken as individual medical advice, nor is it intended as a substitute for consulting your doctor and/or healthcare practitioner.  All material presented on the blog ,newsletter or within its communications has been sourced from multiple authors and does not necessarily constitute the opinion of  InterConnective Health.It is provided for general information and educational purposes only.  Serious injury or illness should not be treated without expert advice, nor should the information we provide be seen as a replacement for a consultation with a trusted healthcare provider and General Practitioner. It is your responsibility to seek medical help and diagnosis when appropriate. All remedy related information is drawn from homeopathic pharmacopoeias and materia medicas referenced worldwide.

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© 2020 by InterConnective Homeopathy.