Comfort Care Request Form

Who is filling out this form?(Required)

I am the person needing care (Client)

I am filling this out on behalf of the client (Representative)

Client Information

Client Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

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

Phone Number(Required)

Email(Required)

Please let us know about the care needs of the client(Required)

Client has a life-limiting diagnosis

Client is eligible for hospice care

Client is in need of transition care (eg. palliative/end of life care)

Not sure/need guidance on care options

Please let us know about your care needs

I have a life-limiting diagnosis

I am eligible for hospice care

I need support with treatment side-effects

Not sure/need guidance on care options

Please tell us about what the client is experiencing:

Please tell us about what you are experiencing:

Representative Information

Representative Name

First Last

What is your relationship to the client?

Please specify your relationship to the client:

Representative Phone Number

Representative Email Address

Have you been appointed as the client’s Medical Power of Attorney?

Yes

Advanced Directives

Does the Client have an advanced directive?

Yes

Do you have an advanced directive?

Yes

Contact for Follow-up

Who should we contact about this request?

Client

Representative

Preferred contact method

Phone

Consent (Please Scroll to Read)(Required)

I wish to have homeopathy as part of my end of life care, I verify that I have read and understand the terms of service outlined below, and hereby give my consent for care.

Our work together

• HHN Comfort Care is an initiative of HOHM Foundation and provides access to safe and accessible homeopathy care while engaging in outcomes-based clinical research in conjunction with The Academy of Homeopathy Education.
• Homeopathy views health from a holistic perspective. Homeopaths do not make a medical diagnosis. 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 suggestions be taken as a medical diagnosis, nor should recommendations be seen as direction against a licensed medical or mental health care professional’s advice.

By agreeing to HHN’s terms of service you agree to the following:

• I understand that the goal of homeopathy is to increase general vitality and help support the body in its day to day functions. No specific disease will be diagnosed or treated.
• I authorize discussion of my case notes with other homeopaths and/or health care professionals should assistance in remedy selection and/or case analysis be necessary or if my best interest is served by such a consultation.
• I am over 18 years of age and have voluntarily chosen homeopathy care for myself.
• I am aware that the outcome and duration of homeopathy care may vary by individual and cannot be guaranteed, and that the assigned practitioner offers no warranty or guarantee as to the outcome of the homeopathy care.
• I agree that I have a choice with regard to where I obtain the homeopathic remedies recommended.
• This Agreement shall be governed by the laws of HOHM Foundation’s incorporating State of Delaware and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the practitioner resides.
• The Parties agree that the terms and provisions of this Agreement embody their mutual intent 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 or treat disease. All recommendations are for supporting the body only.

In the event of a medical emergency, immediately seek care with your licensed medical provider or Emergency Department.

Consent (Please Scroll to Read)(Required)

The Client wishes to have homeopathy as part of their end of life care, I verify that I have read and understand the terms of service outlined below, and hereby give my consent for care.

Our work together

• HHN Comfort Care is an initiative of HOHM Foundation and provides access to safe and accessible homeopathy care while engaging in outcomes-based clinical research.
• Homeopathy views health from a holistic perspective. Homeopaths do not make a medical diagnosis. 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 suggestions be taken as a medical diagnosis, nor should recommendations be seen as direction against a licensed medical or mental health care professional’s advice.

By agreeing to HHN’s terms of service you agree to the following:

• I understand that the goal of homeopathy is to increase general vitality and help support the body in its day to day functions. No specific disease will be diagnosed or treated.
• I authorize discussion of the Client's case notes with other homeopaths and/or health care professionals should assistance in remedy selection and/or case analysis be necessary or if the Client's best interest is served by such a consultation.
• I am the medical power of attorney for the Client needing care and have voluntarily chosen homeopathy care for the client.
• I am aware that the outcome and duration of homeopathy care may vary by individual and cannot be guaranteed, and that the assigned practitioner offers no warranty or guarantee as to the outcome of the homeopathy care.
• I agree that I have a choice with regard to where I obtain the homeopathic remedies recommended.
• This Agreement shall be governed by the laws of HOHM Foundation’s incorporating State of Delaware and the venue of any action brought concerning the interpretation or enforcement of this Agreement shall be proper in the county the practitioner resides.
• The Parties agree that the terms and provisions of this Agreement embody their mutual intent 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 working with the Client is not a medical doctor and does not diagnose or treat disease. All recommendations are for supporting the body only.

In the event of a medical emergency, immediately seek care with a licensed medical provider or Emergency Department.

Research Consent(Required)

Yes, I consent to have the anonymized clinical information from my case used for research purposes.

No, I do not consent to have the anonymized clinical information from my case used for research purposes.

I consent to have my anonymized clinical information from my case used for research purposes. I understand that my right to privacy will be protected. All potentially identifying personal information is removed in all HOHM research. I also understand that I have the right to withdraw consent to have my information used for research purposes at any time by contacting [email protected]. For any questions about the nature and scope of the research, you can contact [email protected].

Research Consent(Required)

Yes, I consent to have the anonymized clinical information from the Client's case used for research purposes.

No, I do not consent to have the anonymized clinical information from the Client's case used for research purposes.

I consent to have the Client's anonymized clinical case information used for research purposes. I understand that the Client's right to privacy will be protected. All potentially identifying personal information is removed in all HOHM research. I also understand that I have the right to withdraw the Client's consent at any time by contacting [email protected]. For any questions about the nature and scope of the research, you can contact [email protected].

Signature of Client or Representative

If you don't get an email confirmation the form was not submitted. Please resubmit and check that all fields are completed.

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