Informed Consent/Disclosure (Homeopathy Services)

Informed Consent and Disclosure: Homeopathy Services

Patient Name: [Patient full legal name]
Date of Birth: [MM/DD/YYYY]
Medical Record Number: [MRN or unique ID]
Date/Time of Consent: [MM/DD/YYYY HH:MM]
Location: [Clinic location]

Practice and Practitioner Information

Practice/Facility Name: [Practice or facility name]
Practice Address: [Street, City, State/Province, ZIP/Postal Code]
Contact Phone: [Main phone number]
After-Hours Instructions: [How to reach on-call or message service; expected response times]
Emergency Instructions: For emergencies or severe/worsening symptoms, call 911 or go to the nearest emergency department.

Responsible Practitioner: [Practitioner full name]
Credentials: [Degree(s)/Certification(s)]
Licensure: [License type and professional title] — State/Province: [State/Province] — License Number: [License number] (Include if applicable)

Scope of Practice Statement:
[Services provided, such as: homeopathic assessment and remedy recommendations / wellness and lifestyle counseling / comprehensive care including diagnosis and prescribing where permitted]
[Services not provided, such as: medical diagnosis / prescription medication management / emergency or urgent care / procedures] (Customize for practitioner's actual scope)

Unlicensed Practitioner Disclosure: (Include only if practitioner is not licensed as a healing arts provider in the jurisdiction)
I am not a physician or licensed healthcare provider in this jurisdiction. My services are complementary/alternative in nature and are not a substitute for medical diagnosis or treatment. [Applicable licensure exemptions or registration status]. My training includes: [Summary of relevant education, training, and experience]. You are encouraged to maintain care with a licensed primary care clinician and specialists as appropriate.

Description of Homeopathy Services

Homeopathy is a complementary/alternative health approach that uses highly diluted substances to select remedies based on an individualized review of symptoms and health history.

• [Health history intake process and symptom review]
• [Remedy selection process, dosing instructions, and guidance on when to report changes]
• [Follow-up schedule and symptom tracking approach]
• [Lifestyle and self-care recommendations if offered]
• [Product forms used: oral pellets / tablets / liquid preparations / topical products] (Include forms applicable to practice)
• [Dispensing policy: Remedies are recommended and obtained from outside vendors / Remedies may be dispensed by this practice]

Evidence, Benefits, and Limitations

Homeopathy is considered a complementary/alternative approach. Scientific evidence supporting its effectiveness is limited, and specific outcomes cannot be guaranteed. Some patients may report symptom relief, improved well-being, or value from structured follow-up and symptom tracking, while others may experience no improvement.

[ ] I understand that the expected benefits of homeopathy are not certain and that no guarantees have been made.

Risks and Important Considerations

• Possible reactions or sensitivities to remedy ingredients or excipients (inactive ingredients such as lactose or alcohol)
• Potential for symptom changes, including temporary worsening
• Risk of delaying appropriate medical evaluation or treatment for serious conditions if homeopathy is used instead of recommended care
• Out-of-pocket costs: insurance typically does not cover homeopathy services or products
• Homeopathic products are not FDA-approved and have not been evaluated for safety or effectiveness; some products may contain measurable active ingredients; adverse effects or interactions can occur (Include if products are dispensed)

[ ] I understand that using homeopathy instead of or while delaying conventional medical care may affect health outcomes for serious conditions.

Alternatives

• Conventional medical evaluation and treatment (including referral to a primary care clinician or specialist)
• Other supportive or complementary approaches
• Continue current care without adding homeopathy
• Decline homeopathy services entirely

Coordination With Your Medical Care

[ ] I agree to maintain care with my primary care clinician and relevant specialists as appropriate.
[ ] I will inform my conventional healthcare providers about my use of homeopathy and any remedies I take.
[ ] I will not stop or change prescription medications without first discussing with the prescribing clinician.
[ ] I understand that homeopathy services are not emergency care. For serious, new, or worsening symptoms, I will seek emergency evaluation.

Communication and Follow-Up

How to Contact the Practice: [Phone / secure message / email policy]
Expected Response Times: [Typical response window during business hours; after-hours policy]
Follow-Up Intervals: [Typical follow-up timing and scheduling process]
Reporting Concerns: [Instructions for reporting suspected adverse reactions, symptom worsening, or when to seek urgent/emergency care]

Financial Disclosure

(Include if practice sells remedies or supplements)
This practice [does / does not] sell homeopathic remedies or supplements. Products [are / are not] available from other vendors. [Material financial relationships or incentives, if any]. (If a separate financial agreement exists, reference document name rather than duplicating details here)

Patient Understanding and Consent

[ ] I have had the opportunity to ask questions.
[ ] My questions have been answered to my satisfaction.
[ ] I understand the information provided in this document.
[ ] I voluntarily consent to receive homeopathy services and understand I may withdraw consent at any time.

Signatures

Patient Signature: ________________________________
Printed Name: [Patient full legal name]
Date/Time: [MM/DD/YYYY HH:MM]

Legal Representative: (Complete if patient unable to consent)
Signature: ________________________________
Printed Name: [Representative name]
Relationship/Authority: [Parent / Legal Guardian / Healthcare POA / Other]
Date/Time: [MM/DD/YYYY HH:MM]

Practitioner Attestation: I discussed the nature of homeopathy services, potential benefits and limitations, risks, alternatives, and coordination with medical care, and answered questions.
Signature: ________________________________
Printed Name: [Practitioner full name]
Date/Time: [MM/DD/YYYY HH:MM]

Interpreter: (Complete if interpreter was used)
Name: [Interpreter full name]
Language: [Language]
Modality: [in-person / phone / video]
Signature: ________________________________
Date/Time: [MM/DD/YYYY HH:MM]

Copy Provided to Patient: [ ] Yes
Date/Time: [MM/DD/YYYY HH:MM]