General Consent form for North American Clients

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Name

Phone number

Premium Vedic Astrological Remedies Exact Date, Time, Place of Birth

Phone

Address to ship remedies

List all Prescription Medications you are on or have been on

Main issue seeking Homeopathic help

List All major surgeries/ Major health issues you had

Since when your main issues started describe much in details, like symptoms, what makes the main issue better with cold or hot weather, food etc. Any other symptoms happen along with main issues.

Take a head to toe review and describe symptoms and list all health symptoms according like Head – Headache which side and describe how you feel the headache , Head, neck, chest, lungs, abdomen, stools, hips, genitals, legs

Describe a dream and sleep pattern. Especially the ones recurring.

Good faith agreement – Acceptance- Homeopathic disclosure

Print your name as a signature to accept the disclosure and agreement above. Thank You

Enter todays date for accepting the homeopathic disclosure above. Thank You (YYYY-MM-DD)