Homeopathic Consultation Agreement

Nature of work performed: 

I understand that Sima is a classical homeopathic consultant who evaluates my entire condition based on homeopathic approach, and seeks to assist me to stimulate my body’s own healing mechanism with the use of homeopathic medications appropriate for my health complaints. I understand that she is not a medical doctor, has not presented herself as such, and does not seek to diagnose, treat, or prescribe for disease, disorder or other pathological conditions. I understand that Sima Ash may also discuss with me the use of other complementary medicine alternatives to improve my health, and that these are within her scope of practice to the extent that she incorporates them. I agree that I am interested in enhancing my own abilities to establish health in mind and body. I agree to consult a licensed physician for any medical concern that now exists or arises at any time during the term of this agreement, and to inform Sima Ash of my physician’s assessment in so far as it applies to my homeopathic case.

Cost of Consultation:                                                                                                          I agree to pay $300 for initial consult and $125 for follow up consultations. These payments may be paid in cash or by check. Your initial consultation will take up to 2 hours and follow up visits are 30 minutes.

Rights and Responsibilities:

Sima Ash agrees to honor confidentiality and assures professional conduct as defined by the code of ethics of the North American Society of Homeopaths and the Council for Homeopathic Certification. Sima also agrees to elicit a history of indications relevant to my condition, discuss with me accordingly, and guide my selection and use of homeopathic medications in accordance with the principles of classical homeopathy.

I retain the services of Sima Ash as a homeopath, and in order to maximize the benefits received from this work, I agree to provide a summary of medical and non-medical health care services which I have sought or am now considering, along with a complete description of my health history and current conditions. I also agree to provide accurate feedback about the results of homeopathic medicines I take and other complementary actions that I pursue. This agreement becomes part of my homeopathic case records.

Client Signature: _________________________________

Practioner Signature: _____________________________

Date: __________________________________

(in electronic form, please enter name and date here and return form via email)