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.
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
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