Asim Health Center Patient Input Form
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Patient Registration Number
Leave Blank if you do not have one.
Date of birth: *
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First Name *
Last Name *
Address : *
City: *
Postal/Zip Code *
Country *
Phone (Home) *
Phone (Cell) *
Phone (Work)
Occupation *
Family Dr's Name *
Reffering Dr's Name
Would you like to be added to our email list to receive clinic newsletters, event information etc?
Marital Status : *
Sex : *
How did you hear about us *
Required
Other Family member or emergency contact Name, relationship & Phone *
Medical History
Please provide presenting complain and medical history.
Check all that apply : *
Required
Smoker *
Drugs use *
Alcohol Use *
Please list any medicines in use: *
Please list your main health concerns or main complain: *
Current Supplements & dosages (Vitamins, herbal, Homeopathy etc)
Any other info please:
Informed Consent
I, the undersigned, do hereby acknowledge that I have been informed of and understand the assessment and recommended treatment described above and have discussed to my satisfaction this and any requests for related information with the Homeopath . I have been given the opportunity to ask questions about the assessment and recommended treatment and have received answers to such questions. I further acknowledge and confirm that I have been informed of, and understand the procedure(s) with respect to the nature of the procedure, expected benefits, material risks, material side effects and financial cost; the likely consequences of not having the procedure(s), and what alternative course(s) of action are available to me. I understand that I can withdraw my consent at any time. As a result, I do hereby voluntarily provide my informed consent for the recommended treatment specified above.

I, hereby, certify that the information I have provided on this “Patient In-Take Form” and the “Informed Consent
Form”, is correct to the best of my knowledge. By signing below on this form, I affirm that; I am participating in the treatment program with my own free will and informed consent and without any prejudice. I have read and understood the form and the nature of the information required in it.

I understand that like all other methods of treatments, some kind of harm or side-effects of the prescribed medicine
may be involved in this treatment. I, therefore, release  AHC from all claims arising out of, or in
connection with my participation, in the treatment or program. I release the AHC of being responsible, answerable or
accountable for any such risks.

By writing my Full Name  I agree to above mentioned consent. Full Name :   *
*
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