Patient form step 1 Patient details Is the patient 18 years or more? (required) YesNo Relationship to the patientFatherMotherGrandparentSiblingOther(required) Date of Birth (required): Gender (required): ---MaleFemaleOther Your General Practitioner (GP) Details Your Specialist Practitioner Details, if applicable CONSENT TO HOMOEOPATHIC TREATMENT (required) I confirm that I request Homeopathic treatment from this Issa Qandil, fourth year Homeopathic Student