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New Client Questionnaire

Please note that all information provided is kept in the strictest confidence according to the regulations of the client homeopath confidentiality agreement

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Have you ever suffered from any of the following conditions? *please check all that apply:
Have you had any of the following vaccinations?
Your Personality Profile:
Many times your health can be influenced by your emotional state. As an aid to help choose the best homeopathic remedy for you, please choose any and all of the following characteristics that describe YOU the best:
Terms & Conditions of Homeopathy with Jennifer Shelley

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.

If client is under the age of 18, a parent or guardian must sign.

Thank you for submitting!

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