• ADULT HEALTH HISTORY

  • CLIENT DETAILS
  • List all complaints in order of importance to you:

  • List any surgeries you have had and when:

  • Date Format: DD slash MM slash YYYY
  • This information is strictly confidential. Any information obtained during this consultation is confidential.

    Please read and sign below.
  • * I understand that Krista Rivet is not a physician and can neither diagnose nor treat any illness. She is a certified classical homeopath and the relationship between myself and Krista Rivet is one of educator and client. I acknowledge that it is my right and responsibility, at any time throughout my consultations with Krista Rivet to seek medical treatment and diagnosis if so desired by a medical doctor for any present/future condition. I acknowledge that the state of my health is my responsibility and that I am exercising my right to choose an alternative method by choosing homeopathy. By signing below I am stating I am aware and acknowledge all of the above and will choose whether to use the advice/education by Krista Rivet. In the event of an emergency, I must seek the help of a medical doctor.
  • Date Format: MM slash DD slash YYYY

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