Rapid Remedy
e-Consult

INtake Form

Thank you for choosing my Rapid Remedy e-consultation service. Please complete the form below for your practitioner to review. After submitting the form, you will receive an email with instructions on joining our messaging app. The Rapid Remedy e-Consultation provides tailored advice for your wellness needs. Current response time is 24-48 hours, although some replies may be ready sooner.

Name

First Name

Last Name

Email

Phone

Country

(###)

###

####

Which best describes your area of need?

Check all that apply.

General health improvement

Improve or reverse a diagnosis

Immunity or infection

Women's health

Men's health

Something else

Describe Your Health Concern

Please describe your question or health concern briefly.

Medication #1

If taking any medications, please list up to three below. For additional medications, there is a $15 fee per medication for interaction review. Please note the dosage, frequency, and reason for taking.

Medication #2

Medication #3

Additional Medications?

If yes, I will follow up to capture that information and with details about the upcharge.

Yes, I take more than 3 meds and understand there is a $15 fee per additional medication for review.

Not applicable

Allergies

If you have any known allergies to foods, herbs, supplements, or medications, please note them below.

Agreement

I understand that this mini consultation service provides general health and wellness recommendations and is not a substitute for medical advice. I understand that I am not completing a comprehensive health intake form but agree to share complete and accurate information for my consultation.

Confirmation

Please type your name and date to confirm you agree with the terms of this service.

Policy Statement

To provide you with the best possible guidance in a timely manner, here’s what to expect from my mini consults:

Timely Responses:
- I aim to deliver clear, personalized recommendations within 24–48 hours of receiving your consult request.
Medication Reviews:
- If you are currently taking medications, I include a review of up to three medications in the base consult fee.
- For clients on more than three medications, there is an additional fee of $15 per medication to allow for a thorough interaction review.
Ethical & Personalized Care:
- I prioritize accuracy and safety when recommending herbs, supplements, or lifestyle adjustments. This includes cross-checking for potential interactions with any listed medications.
Boundaries:
- Mini consults are designed for specific, focused questions. If your concern is complex and requires a full protocol or more detailed exploration, I may recommend scheduling a longer consultation.
Refunds & Timing:
- Due to the personalized nature of this service, mini consults are non-refundable once I’ve started working on your question.

Rapid Remedy e-Consult

INtake Form

Policy Statement

Categories

Rapid Remedy
e-Consult