Contact Us Form

Contact Form For All Services

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REQUEST A CONSULTATION OR SERVICES
Date
First and Last Name
Your Email	Check for accuracy! This form will only submit with a valid email address.
Name of Person for Care (First and Last)
Age of Person for Care
*Cell Phone(s)*
Skype address	Enter N/A if you do NOT* have a skype address for free video conferencing.*
*Address*
City
State / Province
Zip Code
Country	We accept clients living in the USA - or with a shipping address in the USA.
CURRENT HEALTH ISSUE(S)
Select the Main Type Of Homeopathic Care Select the main one from these options.	Please choose only 1.
What is the MAIN ISSUE or DIAGNOSIS that are you are seeking homeopathic care for? Please select the ONE (1)* Main Health Concern that applies to the person the you are seeking care for.* If there is a medical diagnosis made, pick the MAIN ONE* diagnosis that matches the main issue.* You will explain more* details in the comments section below.*	Please choose only 1, the main issue.
How long has the main issue been a health condition?	Please choose only 1.
Name each current or suspected diagnosis, in chronological order with the year it started after each. List any active medial diagnosis within the last 5 years.	If NONE, enter N/A.
Number of total current diagnoses	Write in the total number of all current **or suspected current diagnosis(es).**
Has the person or member(s) of the immediate household received any Covid pandemic vaccine(s)?	Please choose only 1.
Is the person for care a Christian?	Please choose only 1.
ADDITIONAL COMMENTS
COMMENTS: Please provided us with more general details on the nature of your inquiry.	Please add your comments to submit this form. You must submit something below to submit this form. Limit what you write to the space provided.
*How did you find out about us?* Please choose only one.
Have you ever used homeopathy before or worked with a professional Homeopath before? If YES, please give the name of last Homeopath.	Select only one. If YES, please give the name of your most recent homeopath below. If NO, enter N/A. You must enter something below in order to submit this form.
If you are a REFERRAL, please provide the name of the person who referred you.	Enter the name of the person who referred you below. If this is not a referral, just enter N/A. You must enter something below in order to submit this form.

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If you can't submit this form, email: info (at) HomeopathyForWomen (dot) org

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Thank you!

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