Homeopathic Wellness Assessment Online Form "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Client InformationName* First Middle Last Home Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Alternate PhoneBest number to leave a confidential messageEmail* Would you like to receive our newsletter? Yes No Marital StatusSingleMarriedPartnerDivorcedWidowSeparatedNumber of ChildrenAge*Date of Birth* MM slash DD slash YYYY HeightWeightOccupationReferred byBriefly describe the concerns that brought you here todayTerms of Assessment By signing this document I understand that Myra Nissen agrees to honor confidentiality and assures professional conduct as defined by the Council for Homeopathic Certification. Myra Nissen further agrees to elicit a history of indications relevant to my condition, discuss with me accordingly, and guide my selection and use of homeopathic remedies in accordance with the principals for classical homeopathy. I understand that the State of California does not offer licenses in homeopathic medicine, and Myra Nissen is not a physician. Homeopathy is alternative and complementary to healing arts that are in accordance with Sections 2053.5 and 2053.6 of the State of California Business and Professions Code that was provided for by 2002 SB 577 commonly known as the Alternative Health Care Freedom Act. If you are at all concerned about your health, please consult your licensed physician or appropriate health care professional.Accepted Terms* I have read and agree to the terms of assessment.
