Follow up

This follow-up form is for the use of patients who have already had an online consultation with David Doré

Pay online with your credit card. Payment can be made by credit card using the PayPal option on this site. It is a secure online payment service for maximum security.

Please provide the following information:

Name


Title


Work Phone


Home Phone


FAX


E-mail

Please complete ALL the information below:

After taking your medicine did you notice, in general, any changes in your sense of well being?

Yes
No
Same

Since your last treatment, is your energy.

Better
Worse
Same

Please indicate below any changes, however slight, in your main symptom or complaint.



Are the above changes continuing? Yes No

Phobias/Anxieties/Depression etc. (if applicable). Please describe any changes.

Are the above changes continuing? Yes No

Physical problems (if applicable). Has your physical health altered in any other way?

Are the above changes continuing? Yes No

Any further comments?


When completed, please click on submit below. Your treatment details and medicines will then be forwarded to you by post on receipt of payment.

Your Homeopath fee for this treatment is UK £25.00 and your Credit Card will be debited with this amount.

Payment:
Pay Pal Cheque (UK Residents Only)