Edi Pfeiffer, C.C.H, R.S.Hom.
New Client Intake Form
Date___________________
First Name____________________________ Last Name_________________________ Address_________________________________________________________________ City__________________________ State______ Zip____________________________
Phone (Home)___________________Work________________ Cell________________
Email address____________________________________________________________
Age________ Date of Birth___/___/_____
Referred by____________________________________________________
Patient’s Condition________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Duration of problem_______________________________________________________
Family history of major illness (cancer, heart disease, diabetes, autoimmune problems,
mental illness, etc.)________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ __
Doctor_________________________ Doctor’s Phone#_________________
If Child Parent or Guardian_______________________________________ Siblings_______________________________________________________
If Adult Occupation_____________________________________________
Emergency Contact Name and Phone # (other than parent)_________________________
Fees
• Initial Consultation: $300
• Follow-up visit: $150 per hour
• Family Discount: 15% less for second and subsequent family members
Office Policies
• 48 Hour Cancellation Notice Required
• Charge for no shows and late cancellations is half of missed visit fee
• I do not bill insurance, invoice available on request for Health Savings Accounts
• Payment required at time of visit, cash, check, or credit cards accepted
I have read and agree to honor all office policies
Signed_______________________________________________________________
California Senate Bill SB-577
Disclosure statement
Patient Disclosure
To: _________________________________
(name of client)
Welcome to my practice. As you know, I am a practitioner of homeopathy. I am not a licensed physician, nor are homeopathic services licensed by the state.
Homeopathy is based on the notion that like cures like. This means that a substance that causes a particular set of symptoms in a healthy person can cure the same or similar symptoms in a person who is ill. Homeopathy calls these substances remedies. The correct homeopathic remedy sets up a process of healing that can continue for months or years.
As a practitioner of homeopathy, I will provide you with a personalized analysis of your unique pattern of interrelated characteristics. These include your physical and emotional symptoms, your diet, your sleep patterns, etc. I will match these characteristics with a particular homeopathic remedy, which I will sell you directly from a dispensing kit of remedies provided by Hahnemann Laboratories or have you purchase from a local pharmacy. We will schedule an appointment for 4-6 weeks later to evaluate your progress with this remedy, and then schedule another appointment for 1-2 months after that. I am available by phone or appointment in between these visits.
I have been practicing homeopathy since 1991. My training and education is described below:
Society of Homeopaths Course; London, England; 1980-82
Homeopathic Study Group; Berkeley, California; 1982-1985
George Vithoulkas Seminars; Berkeley, California; 1986 and 1987
Hahnemann College of Homeopathy; Berkeley, California; 1988-91
Human Biology Courses; Laney College, California; 1991-93
Luminos Homeopathic Master Clinician Course; Tiburon, California; 2001-03
In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy. I will keep the original in my records for at least three years.
My method of treatment, 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 Professions Code, I can offer you these homeopathic services, subject to requirements and restrictions that are described fully below.
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.
Under the terms of 2053.5 of the California Business and Professional Code, Non-licensed health care practitioners may offer their services so long as they do not:
- Conduct surgery or any other procedure on another person that punctures the skin or harmfully invades the body.
- Administer or prescribes x-ray radiation to another person.
- Prescribe or administer legend drugs or controlled substances to another person.
- Recommend the discontinuance of legend drugs or controlled substances prescribed by an appropriately licensed practitioner.
- Willfully diagnose and treat a physical or mental condition of another person under circumstances or conditions that cause or create risk of great bodily harm, serious physical or mental illness, or death.
- Set fractures.
- Treat lacerations or abrasions through electrotherapy.
- Hold out, state, indicate, advertise, or imply to a client or prospective client that he or she is a physician, a surgeon, or a physician and surgeon.
A person who advertises any services that are not unlawful under Section 2051, 2052, or 2053 shall disclose in the advertisement that he or she is not licensed by the state as a healing arts practitioner.
Section 2053.6 of the California Business and Professions Code, specifies that:
a) A person who provides services pursuant to Section 2053.5 that are unlawful under Section 2051, 2052, or 2053 shall, prior to providing those services, do the following:
- Disclose to the client in a written statement using plain language the following information:
- Obtain a written acknowledgement from the client stating that he or she has been provided with the information described in paragraph (a). The client shall be provided with a copy of the written acknowledgement, which shall be maintained by the person providing the service for three years.
b) The information required by subdivision a) shall be provided in a language that the client understands.
Acknowledgement and Consent to Receive Services:
I have read and understand the above disclosure about the homeopathic treatment offered by Edi Pfeiffer and Edi’s training and education. I have discussed with Edi the nature of the services to be provided. I understand that Edi Pfeiffer is not a licensed physician 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. I have consented to use the services offered, and agree to be personally responsible for the fees of Edi Pfeiffer in connection with the services provided to me.
Signed: _________________________________ Date: _________________________
(client/parent/conservator/guardian)
Indicate capacity to sign if other than client ________________________