Pre-consultation questionnaire

Please fill out this Questionnaire form before your consultation.

Name *

First

Last

How did you know about me? *

• Internet
• Word of mouth
• Friends
• ARH website
• Ainsworths Pharmacy
• The Organic Pharmacy
• Look up on findahomeopath.org

Why would you like to have Homeopathic treatment? *

What is your expectation from this consultation? *

Have you taken Homeopathic remedies in the past? *

Is it your personal decision to take Homeopathic remedies? *

• YES
• NO

Email *

Submit