Supervision Consultation Payment Form

Student Supervision Payment Form

Contact Information
Your Student Practitioner's Name*
First Last
Your Name*
First Last
Your Email*
Your Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you the one needing care? - Adults (or parent if a minor) must sign Consent Form below*
- Yes
- No
Your relationship to the client:*
Does the client know you're contacting Homeopathy Help Now on their behalf?*
- Yes
- No
Client Name*
First Last
Client Phone*
Client Email*
Payment Information
Consultation Fees*

Credit Card*

Cardholder Name

Card Details

Total
$0.00
Read the consent and continue to the bottom to sign and submit the form.
Agreement for Consultation
Our work together

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 (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 Homeopaths if my (my child’s) best interests are served by such a consultation. My right to privacy will be protected by withholding my name and any other identifying information.
- I am over 18 years of age and have voluntarily chosen homeopathic care for myself/my child.
- I am aware that that the outcome and duration of homeopathic care vary by individual and cannot be guaranteed. And that the assigned Homeopath further offers no warranty or guarantee as to the outcome of the homeopathic care.
- I agree that I have a choice with regard to where I obtain homeopathic medicines recommended.
- I am aware that my assigned Homeopath is working on a voluntary basis and as such, I waive all legal rights that may arise from the homeopathic care and hold the assigned Homeopath harmless from all claims, present and future, known or unknown, in any manner arising out of the homeopathic care.
- This Agreement shall be governed by the laws of the State of Arizona 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 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. All recommendations are for wellness and overall health building purposes.
Client Consent & Signature*
I verify that I have read and understand the terms of service outlined on the Terms of Service page.
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Student Supervision Payment Form

Contact Information

Payment Information

Agreement for Consultation

Our work together

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