Accept Form

Date of Birth:   [dd-mm-yyyy]
Postal Address: 
E-mail Address:
Registration ID



I understand that all information on the form will be kept in strict confidence between David Johnson and Dr. Leela.
The information on the form is accurate and provided to the best of my knowledge.
I will contact my local health care professional for any and all emergencies.
I understand that homeopathic remedies are extremely safe, but during the process of healing I may experience temporary nuisance symptoms (eg., muscle soreness, etc.), which are beyond the control of the homeopaths.
I agree to pay at three-month intervals for as long as I choose to continue and the doctors and I jointly conclude I am experiencing benefit from collaboration.