Help No Matter Where You Are!
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Health History
This five page intake form provides us with the necessary information to address your healthcare options holistically. You may open this word document, type your answers into the form and email it to us.
Homeopathy
Constitutional homeopathic remedies can support any other healing modalities you choose as well as acute situational remedies. Download the form HERE for the bach flower essence assessment
Homeopathic intro and instructions |
Long Distance Program
Distance consults are a great way to get affordable healthcare with quick results.
1. Fill out the INTAKE FORM 2. Get a phone consult scheduled Adrenal Fatigue Self-Assess
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Need Essential Oils?
STEP 1
Read the Informed Consent:
Read the Informed Consent:
INFORMED CONSENT
1. I hereby authorize Heather Holistics and all representatives to act on my behalf concerning the corrective, therapeutic, natural, non-drug, non-evasive protocols offered to achieve health. I specifically authorize for my health to be evaluated based on holistic concepts and for the appropriate nutritional and detoxification protocols, lifestyle, and environmental modifications to be recommended.
2. I warrant that all information submitted for the purposes I am of seeking advise is submitted by me and is true to the best of my knowledge.
3. I understand I am not attending an allopathic doctor (MD), and do not diagnose disease.
4. I understand that I will not receive allopathic drugs, surgery, chemical stimulants, or any other allopathic services. I understand the programs recommended are in no way to take the place of allopathic medical treatment and if I desire further information or services not provided I will seek them elsewhere.
5. Heather Holistics is available to work with my medical doctor or any other health care provider to implement a program of integrative wellness.
6. All information disclosed will be kept confidential except under the circumstances of law enforcement requirements.
7. The programs recommended are to promote health and healing, and to boost my body's immune system by natural supplementation, energetic protocols, alternative therapies, and lifestyle modification.
8. I understand quantum biofeedback is designed to reduce stress and pain naturally and non-evasively by enhancing the flow of energy throughout the body. The biofeedback device is regulated by the Food and Drug Administration (FDA) and registered for stress and pain detection and reduction.
9. The Biofeedback device, nor the practitioner operates by diagnosing or prescribing. In addition no services provided are intended to treat, or prescribe for my disease or conditions, nor perform any act that constitutes in the practice of medicine for which a license is required.
10. I understand the importance of communication with my physician and my responsibility to ask my medical doctor for permission to undergo biofeedback training if I wear a pacemaker or have any medical condition that may be exacerbated by relaxation.
11. Recommendations for other services/practitioners are only the advice of the practitioner I have consulted with and only to be followed if I believe it to be beneficial to my health and well-being.
12. I have solicited to this form of natural healthcare and understand Heather Holistics' services are not to substitute for standard medical, chiropractic, or psychotherapy treatment, nor veterinary care for my pet.
13. All information disclosed will be respected and kept confidential.
14. There will be a fee for returned checks.
15. A minimum fee of $20 or 20% of the set consult fee is charged for no-show appointments.
16. Heather Holistics does not deal directly with insurance companies but will provide an invoice. There are no refunds for the services provided.
1. I hereby authorize Heather Holistics and all representatives to act on my behalf concerning the corrective, therapeutic, natural, non-drug, non-evasive protocols offered to achieve health. I specifically authorize for my health to be evaluated based on holistic concepts and for the appropriate nutritional and detoxification protocols, lifestyle, and environmental modifications to be recommended.
2. I warrant that all information submitted for the purposes I am of seeking advise is submitted by me and is true to the best of my knowledge.
3. I understand I am not attending an allopathic doctor (MD), and do not diagnose disease.
4. I understand that I will not receive allopathic drugs, surgery, chemical stimulants, or any other allopathic services. I understand the programs recommended are in no way to take the place of allopathic medical treatment and if I desire further information or services not provided I will seek them elsewhere.
5. Heather Holistics is available to work with my medical doctor or any other health care provider to implement a program of integrative wellness.
6. All information disclosed will be kept confidential except under the circumstances of law enforcement requirements.
7. The programs recommended are to promote health and healing, and to boost my body's immune system by natural supplementation, energetic protocols, alternative therapies, and lifestyle modification.
8. I understand quantum biofeedback is designed to reduce stress and pain naturally and non-evasively by enhancing the flow of energy throughout the body. The biofeedback device is regulated by the Food and Drug Administration (FDA) and registered for stress and pain detection and reduction.
9. The Biofeedback device, nor the practitioner operates by diagnosing or prescribing. In addition no services provided are intended to treat, or prescribe for my disease or conditions, nor perform any act that constitutes in the practice of medicine for which a license is required.
10. I understand the importance of communication with my physician and my responsibility to ask my medical doctor for permission to undergo biofeedback training if I wear a pacemaker or have any medical condition that may be exacerbated by relaxation.
11. Recommendations for other services/practitioners are only the advice of the practitioner I have consulted with and only to be followed if I believe it to be beneficial to my health and well-being.
12. I have solicited to this form of natural healthcare and understand Heather Holistics' services are not to substitute for standard medical, chiropractic, or psychotherapy treatment, nor veterinary care for my pet.
13. All information disclosed will be respected and kept confidential.
14. There will be a fee for returned checks.
15. A minimum fee of $20 or 20% of the set consult fee is charged for no-show appointments.
16. Heather Holistics does not deal directly with insurance companies but will provide an invoice. There are no refunds for the services provided.
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