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Emergency Contact Name and Phone
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Myself (I am 18 or older)
A minor or dependent in my legal care
If for a minor: Minor’s full name and date of birth
If for a minor: Your relationship (parent or legal guardian)
Vedic Astrological Homeopathy: Patient’s Date of Birth (MM/DD/YYYY)
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Vedic Astrological Homeopathy: Patient’s Place of Birth (City, State/Province, Country)
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Vedic Astrological Homeopathy: Patient’s Time of Birth (as exact as possible, e.g. 3:45 AM; write Unknown if not known)
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Tell your story in your own words. What brings you here?
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When did this concern begin, and what was happening in your life at that time?
What makes it better? What makes it worse?
Current medical issues (allopathic diagnostic test)
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Current medications and supplements (or write None)
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For chronic illness, are you attended by your physician?
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I have read and understand the Disclaimer: Claims hereby are based on Homeopathic Principles only and my theory of Accumulation (health issues in the broadest sense, including Spiritual-Cosmic, Mind, and Emotional levels) in one’s lifetime and discharge of such accumulation using Vedic Astrological Homeopathy and other specialty remedies/medicines mentioned. Please do not compare to Evidence Based Medicine. Building assurance and trustworthiness among clients with experience and expertise.
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I have read and understand the Medical Disclaimer: Homeopathic services and consultations offered through this website are intended to support general well-being and are complementary in nature. These services are not intended to diagnose, treat, cure, or prevent any medical condition and are not a substitute for professional medical care, advice, or treatment. Always consult a licensed physician or qualified healthcare provider regarding any medical concerns or before making changes to your healthcare regimen. Patel’s Homeopathy Consultations LLC does not provide medical diagnoses or emergency medical services. Use of this website and its services is at your own discretion and risk.
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I understand and accept that many processes of homeopathy, including remedies such as Vedic Astrological Homeopathy Remedies, Anti-Stress Remedy, Toxic Memory Removal Remedy, Spinal and Knee Pain Remedy, and Modified Constitutional Remedy, will not be disclosed to me. This protects the integrity of the practice and prevents intentional copying of the process and remedies.
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I have read and agree to the Terms and Conditions: (1) Not Medical Advice: The content and services provided are for informational and wellness support purposes only and do not constitute medical advice, diagnosis, or treatment. Always consult a licensed healthcare provider for medical concerns. (2) No Guarantees: Individual experiences may vary. No outcomes or results are guaranteed. (3) Use at Your Own Risk: You are solely responsible for how you use the information or services. Patel’s Homeopathy Consultations LLC is not liable for any outcomes, direct or indirect, resulting from use. (4) Intellectual Property: All website content is the property of Patel’s Homeopathy Consultations LLC and may not be copied, reused, or distributed without written permission. (5) Eligibility: You must be 18 years or older to use our services for yourself; a parent or legal guardian may request services on behalf of a minor in their care by accepting these Terms on the minor’s behalf. (6) No Professional Relationship: Use of this website does not establish a doctor-patient or licensed practitioner-client relationship. (7) Changes to Terms: We may update these terms at any time. Continued use of the website implies acceptance of the revised terms. (8) Governing Law: These terms are governed by the laws of the State of Florida, USA.
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I have read and understand the Privacy Policy, including how my information is collected, used, and protected, my privacy rights under applicable U.S. state laws (including CCPA/CPRA for California residents), and that Patel’s Homeopathy Consultations LLC does not sell or rent personal information.
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If this form is for a minor or dependent: I confirm that I am the parent or legal guardian of the minor named above, the information provided is accurate, and I accept all Disclosures above on the minor’s behalf
By typing my full name below, I confirm that all information provided is accurate, and I accept all Disclosures above for myself (or as parent/legal guardian for the minor named above)
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