DMH New Client Forms
1-client contact form
2-recent health form
3-health history
4-family history
pet contact and health form
Divine Monkey Homeopathy
Client Contact Form
FORM 1 OF 4
Please complete all 4 forms. Thank you.
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Indicates required field
Name
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First
Last
Today's Date
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MM/DD/YYYY
Date of Birth
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MM/DD/YYYY
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone
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### ### ####
Email
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Occupation
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Place of Birth
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How did you hear about Divine Monkey Homeopathy?
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Emergency Contact #1
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Emergency Contact #2
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HOMEOPATHIC SERVICE NOTICE:
I am aware that homeopathy may be practiced as an alternative healing art in California under sections 2053.5 and 2053.6 of the Business and Professions Code subject to these requirements and restrictions: 1) that the practitioner states s/he is not a licensed physician or health-care provider; 2) that homeopathic consulting services are not licensed by the state; 3) that homeopathic consulting is not represented as nor intended to be a substitute for conventional medical diagnosis or treatment, and that it does not diagnose or treat specific pathological conditions or disease symptoms.
ACKNOWLEDGMENT:
I understand homeopathy is a means of stimulating an individual’s vital energy, with the aim of increasing the general well-being of the whole person through the use of homeopathic remedies. I understand that homeopathic services are not medical treatment and that the homeopath is not a licensed physician. I will not hold Sandi Kaplan liable for my overall health or well-being. I agree to pay the full amount of the charges on or before the date of service. I understand that there will be a 50% charge for missed appointments not cancelled at least 24 hours in advance, whether scheduled to be in person, online or over the telephone.
Agreement
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I agree to the above HOMEOPATHIC SERVICE NOTICE and ACKNOWLEDGMENT. My name below serves as my signature.
SIGNATURE
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Please type in your full name.
Submit
1-client contact form
2-recent health form
3-health history
4-family history
pet contact and health form