Have you ever suffered from any of the following conditions? *please check all that apply:

I understand that Jennifer Shelley is not a medical doctor, but instead a Homeopath. As such, I acknowledge that it is my right and responsibility, at any time throughout my treatment with Jennifer Shelley, to seek medical counsel and diagnosis, if so desired, from a medical doctor, for any present and/or future condition(s). I also reserve the right to terminate homeopathic treatment at any time if so inclined. I acknowledge that the state of my health is my own responsibility and that I am exercising my right to choose an alternative method of treatment, in homeopathy, that addresses my health in its entirety at my own risk.