Appointment Form

HOMEOPATHY · USA

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Request an Appointment

Step 1: Your Health Concern

Tell us about your main concern and why you are booking an appointment.

Urgent or severe symptoms? Please seek urgent medical care rather than waiting for an online consultation.

What is your main health concern? *

How long have you experienced this concern? *

What symptoms are you experiencing, and what makes them better or worse? *

Have you received a diagnosis or had relevant tests? Include dates/results if known.

What would you most like help with during this consultation? *

Preferred consultation type *Online consultationIn-clinic visitNo preference

Step 2: Personal Information

Please share only information relevant to your care.

Full name *

Age / date of birth (optional)

Gender (optional)

City and state/country *

Phone or WhatsApp number (optional)

Email address (optional)

Preferred contact method *Phone callWhatsAppEmail

Best time to reach you

Step 3: Medical History, Lifestyle & Confirmation

This information helps keep your care safe. Write 'None' where nothing applies.

Current medicines (name, dose, and reason) *

Herbal remedies, supplements, or homoeopathic products you use (include doses if known) *

Allergies or previous reactions to medicines, herbs, foods, or supplements *

Other medical conditions, surgeries, or significant health history

Pregnancy, trying to conceive, or breastfeeding (if relevant)Not applicablePregnantTrying to conceiveBreastfeeding

Your usual healthcare professional and any current treatment plan (optional)

Any relevant details about sleep, diet, activity, stress, or daily routine?

Anything else you would like Dr Farah to know before the appointment?

Client Confirmation

Please check each statement that applies.

Accuracy of information *I have provided information that is accurate to the best of my knowledge.

Emergency care *I understand this form does not replace emergency care or necessary evaluation by a licensed healthcare professional.

Medication and supplement safety *I understand I should not stop prescribed medication or start a herb/supplement without checking its safety with an appropriate healthcare professional.

Client signature / typed name *

Date *

Privacy reminder: Send this form and any medical reports only through the secure method provided by the practice. Please do not include payment card details or other unnecessary sensitive information.

Dr Farah Naz

Individual homeopathic consultations with Dr Farah Naz, currently based in the USA. Start a conversation about your health and wellbeing from home.

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Contact

Ask about an appointment

Based in the United States
Online consultations

Homeopathy has not been shown to effectively treat health conditions. It should not replace medical diagnosis, prescribed treatment or emergency care.