RMDY Academy Student Patient Intake Form

1

"The RMDY Academy of Homeopathy 'Guided Cases Program' enables students to develop practice by taking cases independently under the supervision of senior lecturers who guide students in their prescriptions." - RMDY Academy

2

"Consultations are heavily discounted. The student will advise and confirm prior to scheduling an appointment. We appreciate you putting forward your case for consideration." - RMDY Academy

3

As a patient of a student practitioner, you will be asked to commit to an initial consultation and at least two follow-up appointments to support the completion of a case study, which is required for their graduation in August 2026. Please only complete this form if you feel confident in your ability to commit to this process.

4

Please confirm your full name, and if this is for a child please include both your name (parent/carer) and the child's name. For example: Sarah Tobin (adult), and Taylor Tobin (child).

5

Phone number* This field is required.

Area Code

Phone Number

6

Email* This field is required.

example@example.com

7

Where are you located?* This field is required.Please include your State AND Country below

8

What is the patients age?* This field is required.

9

Please explain your main health conditions and concerns? * This field is required.Max 200 words

10

Do you consent to your information being shared anonymously with students and lecturers of RMDY Academy for learning and guidance purposes?* This field is required.Please type your name to agree

11

When I reach out to you, I will let you know whether your case is suitable for inclusion in my case studies. If it is, you will receive a client information sheet and a written consent form, which I kindly ask you to review carefully before your consultation.

If your case is not suitable due to guidelines I must follow, I will provide you with the Academy's guided programme form, giving you the option for another student to take your case if you wish.

12

Do you have access to reliable internet connection, video and audio?Camera phone with a microphone is acceptable.

YESNO