Lucy De Pieri Ph - Serenity Homeopathic Clinic



Lucy De Pieri PhD, DCHSt Johns Street Health and Wellness Professional Centre2226 St Johns StreetPort Moody, BC, V3H 2A7Cell 604 307 5967Tel 604 931 7017REGISTRATION FORMName ................................................................................................................................Address and postal code ...............................................................................................................................................................................................................................................Home phone ............................................... Work phone ..............................................Email..................................................................................................................................Date of birth .......................................... Age ....….......................................................Place and country of birth ..........................................................................................…...Domestic status ..........................................................................................................……Occupation ....................................................................................................................…Do you have any children? …......................................…………………….....................……………………………………………………………………………………………Name of MD .................................................. MD phone # ……………………………Address of MD ………………..........................................................................................Complementary or other health care practitioners .........................................................…………………………………………………………………………………………..Referred by ...................................................................................................................…Lucy De Pieri PhD, DCHSt Johns Street Health and Wellness Professional Centre2226 St Johns StreetPort Moody, BC, V3H 2A7Cell 604 307 5967Tel 604 931 7017INFORMED CONSENT TO HOMEOPATHIC CAREI hereby request and consent to the performance of homeopathic treatment.I understand that Lucy De Pieri is a trained classical homeopath and not a licensed medical doctor. I acknowledge that it is my responsibility to seek medical diagnosis and advice for my present and future conditions.I understand that, as in all health care, in the practice of homeopathy there are some very slight risks to treatment, including, but not limited to, aggravation of complaints.Homeopathy is not covered by the existing government medical insurance plan, but it is included in some extended medical insurance. I agree to pay all fees of the consultation and any remedies as prescribedI have read the above consent, I had the opportunity to ask questions about the consent and my case. This consent form covers the entire course of treatment for my present and future condition(s).Name (Print) …………………………………………………………………………………………….Signature ………………………………………………… Date …………………….…………………Lucy De Pieri PhD, DCHSt Johns Street Health and Wellness Professional Centre2226 St Johns StreetPort Moody, BC, V3H 2A7Cell 604 307 5967 Tel 604 931 7017FEESAdultsInitial homeopathic consultation (2 hours) ……….……………..……$200Follow-ups (20 - 45 minutes) ………………………………………….$ 95Remedy ……………...………………………………………………… $ 17Seniors 60 and over, Children 12 and underInitial homeopathic consultation (2 hours)……………….………$170Follow-ups (20 - 45 minutes) …………………………………………$ 75Remedy ………………………………………………………………. $ 17A 10 minutes contact between appointments are free of charge, but if a condition arise when a different remedy is needed, it will be treated as an acute appointment.Acute care from …............................................................................................... $ 50GST now applicable at 5%. All fees are payable at end of the consultation.Appointments- If you have to reschedule or cancel your appointment time, please give me at least 25 hours or the fees will be charged in full. Thank youName ............................................................... Date .............................................................................Accepted form of paymentCash, cheques (payable to Serenity Homeopathic clinic), Internet e-transfer and credit cards.Lucy De Pieri PhD, DCHSt Johns Street Health and Wellness Professional Centre2226 St Johns StreetPort Moody, BC, V3H 2A7Cell 604 307 5967 Tel 604 931 7017CONFIDENTIAL INFORMATIONPERSONAL MEDICAL QUESTIONNAIREName ........................................................................ Date ..................................................................Current health concerns and date of onset (please include surgeries, injuries, major traumas and conditions that you have never totally recover) ..........................................................................…......................................................................................................................................................................................................................................................………………………………………………………………………………………………………….................................................................................................................................................................... Have you seen an MD for your current problems? ...................................................................………..........................................................................................…….......................................................................…………………………………………………………………………………………………………..Main stresses and particular unhappy times in your life and how they affect you. …………………………………………………………………………………………………………..………………………………………………………………………………………………………......…………………………………………………………………………………………………………..Current medication with dates and adverse reactions if applicable………………………………………………………………………………………………………......…………………………………………………………………………………………………………..Vitamins, supplements, homeopathic remedies and other natural therapies with dates.…………………………………………………………………………………………………………..Have you been treated with homeopathy before? For what conditions and what remedies were prescribed? ………………………………………………….………………………………………………………………………………………………………………………………………………..……Tick as appropriate include dates if possible:ConditionConditionConditionAbscessesAlcoholismAnemiaAppendicitisArthritisAsthmaCancerChicken poxPeritonitisCold soresColitisCrohn’s diseaseDepressionDiabetesDigestive problemsEmphysemaEpilepsyFrequent coldsGallstonesGonorrheaGoutHay feverHeadacheHeart diseaseHepatitisHerpesHIVInfluenzaKidney diseaseLeukemiaLyme diseaseMalariaMeaslesPneumoniaMigraineMonoMultiple sclerosis MumpsParasitesPelvic Inflammatory diseaseChronic Fatigue SyndromeMenstrual problemsProstatitisRheumatic feverRubellaScarlet feverSexual abuseSkin diseaseStrep throatSinusitisStrokeSyphilisTonsillitisTBThyroid diseaseTyphoid FeverVenereal diseaseVenereal wartsWartsWhooping coughWormsYellow fever Any other health challenges not listed above ………………………………………………………….……………………………………………………………………………………………………………Please list describe the general health of your family. If dead, please write cause of death.Father ........................................................................................................................................................Father’s father ...............................................................................................................................Father’s mother ........................................................................................................................….Mother ....................................................................................................................................................…Mother’s mother..........................................................................................................................….Mother’s father ..............................................................................................................................Brothers ................................................................................................................................................….Sisters ..................................................................................................................................................…..If you know of the health condition of other members of your family and / or how they died, please include this information below…………………………………………………………………………………………………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….Your children’s health (if applicable) ....................................................................................................…..................................................................................................................................................................…Your childhood illnesses .............................................................................................................................................................................................................................................................................................…Vaccinations and dates. (if known) …................................................................................................……................................................................................................................................................................…..Adverse reactions to vaccinations and dates ...................................................................................………......................................................................…............................................................................................…………………………………………………………………………………………………………….Any pets in the family? ..............................................................................................................…….....…..Are you on a special diet? ........................………...................................................................………….…………………………………………………………………………………………………………..For how long? .................................................................................…….................................................…Are there any foods or drinks that upsets you? ……………...............................................………....................................................................................................................……..............................................Do you have any of the following: pacemaker; artificial joint; metal plate, pins or screws; ear tubes,dental or other implants? ...........................................................................…………………………….Approximately when was your residence built? .........................................……….................................How long have you moved in? ...............................................................................……..........................Does the residence have problems with dampness or mold? .......................................................…………This information is strictly confidential. Thank you, for your cooperation in completing this form. ................
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