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Intake Form

Please fill out the following form.

Date of birth
Day
Month
Year
Gender
Multi-line address

Please list your main current health complaints (mental or physical). Please describe these issues in detail - list the very first time that you noticed this condition and describe carefully any factors that you suspect may have played a role on its onset and development.

Please write a timeline of all major events in your life. This will assist me to assess your present health problems. Please indicate in chronological order all accidents, illnesses, hospitalisations, surgeries, broken bones, sprains, falls, traumatic and emotional events, major changes in your life up to this point in time. I would also like to know when you had vaccinations, when you started school, changed schools, graduated, failed, got married, had children, separated, divorced, etc.

Please list any of the following ailments in your parents, siblings, grandparents & any other recuring issues throughout the family:

Alcohol/Drug Abuse, Allergies, Alzhiemers/Dimentia, Arthritis, Asthma, Autism, Cancer, Diabetes, Epilepsy, Gonorrhoea, Gout, Hayfever, Heart - disease, stroke, blood pressure, Hypertension, Kidney Disease, Mental Illness - Depression, Anxiety, OCD Paralysis, Physical or Sexual Abuse, Skin - eczema, psoriasis etc, Digestive Disorders, Thyroid Disorder, Tuberculosis

Eczema case: Please send through photos.

For children: Please send 1–2 photos as a baby and 1–2 recent ones.

Consent and Agreement

Homeopaths do not diagnose disease, disorders or medical conditions or make any medical diagnosis. Your practitioner is not a licensed medical physician, and nothing said is medical advice.


I understand that homeopathic medicine, whilst natural and holistic, may occasionally result in the aggravation of pre-existing symptoms or stimulate healing or detoxification responses, which may include loose stools, increased perspiration, skin eruptions and nasal discharges, among others. These reactions are uncommon and normally pass within a few hours to days. I will use discernment to get medical treatment or necessary psychotherapy if necessary.


I understand that homeoprophylaxis is not equivalent to vaccination and is not recognised by governing bodies and does not prevent me from contracting an infectious disease. I understand that there are no guarantees to the efficacy of homeoprophylaxis and I take this risk knowingly.


I understand any therapies that are undertaken of my own free will and accept that the ultimate responsibility for my healthcare is my own. I understand that my practitioner reserves the right to determine which cases fall outside their scope of practice in which event an appropriate referral will be recommended. I agree to assume full responsibility for any manner of loss, injury, claim or damage whatsoever, known or unknown, incurred as a result of my treatment and for any loss injury claim or damage sustained as a result of my attendance and or participation.


Zoe Walters does not guarantee results and you are free to withdraw your consent and to discontinue treatment at any time.

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