INFORMED CONSENT FORM
I,___________________________________________ understand that Sarah Jane Coombes is a
professional Homeopath and Bach Flower therapist. I further understand that she is in no way
professing or holding herself to be a licensed medical doctor.
I understand that any treatment provided is in no way intended to replace any treatment recommended
by a physician and it is my responsibility to maintain a relationship for myself or my dependents with
a medical doctor.
Homeopathy is not covered by the existing government medical plan so I agree to pay the full fees as
per the current rate schedule set out by Sarah Jane Coombes. I agree to pay for all charges incurred for
cancelled or missed appointments where 24 hours notice has not been given. I understand that fees are
non- refundable.
In consulting with a homeopath I am exercising my right to choose a complimentary method of
treatment to address my health. Homeopathy is a system of healing not yet fully recognised by the
FDA. Therefore, as a client I understand that no claims or guarantees can be made as to its
effectiveness.
I authorise discussion of my case notes with other professional Homeopaths should assistance in case
analysis be required. I acknowledge that my right to privacy will be maintained through the changing
of my name and all identifying information.
Knowing this I declare I have made a personal choice to seek Homeopathic treatment from Sarah Jane
Coombes and maintain the right to refuse any treatment methods that are suggested.
Print Name of Client_____________________________________ Date _________________
Signature _____________________________________________
Signature of Homeopath__________________________________
Sarah Jane Coombes, LicISH, Registered ISHom and Bach Flower Therapist
www.anewleaf.me