Patient Disclosure

To: ________________________________                     Date:______________________

(Client’s Name)

Welcome to the Healing4soul. I am a classical homeopath and CEASE certified practitioner. I am NOT a licensed physician, nor are homeopathic services licensed by the State of California.

Homeopathy is one of the leading health care systems around the world, treating an estimated 500 million people. It offers holistic, non-toxic, low-cost health care through the application of individual remedies chosen from more than 2,500 FDA-approved remedies in the Homeopathic Pharmacopeia of the United States. Homeopathy provides therapeutic, curative and preventative effects based on the Law of Similars (“like cures like”) and a process of potentization that developed from the scientific work of German physician Samuel Hahnemann over 200 years ago.

The services that I provide are:

Case taking: In-depth interview to record your physical, mental and emotional characteristics and symptoms.

Recommendation: Evaluation and cross-referencing of reported symptoms. The goal is to identify the deeper causative factors and use of isopathy and classical homeopathy to bring the body back into balance and equilibrium

Follow-up: Monitoring your case to evaluate how you improve or change during treatment. Adjustments to remedy and potency as needed will  achieve the most rapid, gentle and permanent restoration of health.

To use my services, California state law requires that you acknowledge receipt of the information provided in this form by signing it. You will receive a copy. I will keep the original in my records for at least 3 years.

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving homeopathic treatment.

This method of treatment, classical homeopathy, is alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Profession’s Code, I can offer you these services, subject to requirements and restrictions that are described fully below.                                               Please initial your acceptance of these sections of SB-577, California Business &Professions Code:                                                                                                                                                                   ____ Section 2053.5: I, the client, understand that this treatment will NOT include any of the following by the provider: puncturing of my skin, invasion or insertion into my body, X-rays or prescription for X-rays, giving or prescribing of legend drugs or controlled substances, telling me to discontinue any legend drug or controlled substance prescribed for me by a licensed practitioner, diagnosing of physical or mental disease, setting of fractured bones, or the use of electrotherapy to treat lacerations [cuts] or abrasions [torn  skin]                                                                                                                             ____ Section 2053.6(a): I, the client, have been given my own copies of this form and any other written materials, as may be indicated above. I have initialed each topic to indicate my understanding or receipt.                                                                                              ____ Section 2053.6(b): I, the client, have been provided with this information in a language that  I understand.                                                                          

Acknowledgment and Consent to receive services:                  

I have read and understand the above disclosure about the homeopathic treatment offered by Sima Ash.  I have discussed with Sima, the nature of the services to be provided. I understand that Sima Ash is not a licensed physician and that she is a classical homeopath and CEASE certified practitioner and that homeopathic services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor if I choose to.                                                                                                            

I have consented to use the services offered by Sima Ash, and agree to be personally responsible for all fees accrued in connection with the services provided to me.

Client Signature: ____________________________________________ Date:_____________________

Printed Name: _____________________________________________________________

Address:____________________________________________________Zip:___________

E-mail:____________________________________________ Phone:_____________________________

Business Phone:___________________________________

Client’s Guardian, if client is a minor:

Guardian’s printed name:_________________________________

Signature:___________________________