Intake Form

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Intake Form

Thanks for your interest in becoming a Reflections client. Please fill out the form below to the best of your ability so that we can get to know your health history. If you have any trouble with the form below or would rather download and submit a PDF, you can access that here.

Reflections Homeopathy Intake Form

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Name*
First Last
Email*
Enter Email Confirm Email
Preferred phone number:*
Current health concern(s):*
Have you seen an MD for your current problem(s)?*
- Yes
- No
Have you/do you see other alternative practitioners for your current or past condition?*
- Yes
- No
Have you taken homeopathic remedies before?*
- Yes
- No
Past major illnesses:
Past hospitalizations:
Have you ever had any adverse reactions to medications, vaccinations, etc.?*
- Yes
- No
Current medications:
Past medications:
Vitamins or natural therapies:
Do you smoke?*
- Yes
- No
How much do you smoke?

Family History
Please list the age, state of health and past major illnesses of family members. If deceased, please include the cause of death.
Father:
Father's mother:
Father's father:
Mother:
Mother's mother:
Mother's father:
Brothers and sisters:
Your children:
Other family information:

Contact Info

Address
Vancouver Centre for Homeopathy #120-3195 Granville St. Vancouver, BC V6H 3K2
Phone Number
604-733-6811 604-786-6095
Email
tina@reflectionshomeopathy.com
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About Us

Homeopathic remedies are natural, gentle and effective. In my 20+ years as a nurse treating patients with various degrees of illness and injury. I have found that natural healing through homeopathy has the ability to provide long term positive shifts in a persons well being , and not just provide a ‘band-aid.’

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Intake Form

Reflections Homeopathy Intake Form

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Family History