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Acute Inquiry

Homeopathy For Women
"Let Miracles Find You!"

Classical Homeopathic Care Using Gentle Water Dosing.
Treating Women, Children & Families *
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Homeopathic Acute Care Prescriptions and 7 Day Support By Email
For conditions lasting 30 days or more, you must request Chronic Care.

Basic Acute Care: $75 for 7 consecutive days. Care is provided in the USA only.
Contagious Acute Care: $150 for for 7 consecutive days. Care is provided in the USA only.

This includes whooping cough, strep throat and other serious infectious diseases.
Acute Clients must have a
200C remedy kit on hand in their household in order in order for us to accept the acute for care.

Homeopathy is NOT urgent care!
For
urgent or life-threatening issues, call your medical doctor or 911 now.

Please submit a new Acute Care request ONLY during business hours.  Acute Care Business Hours: Monday to Thursday from 9:00 am to 1:00 (PST).

We will NOT reply to or begin any acute requests submitted after business hours, on all Fridays, on any weekends and all legal USA holidays.

We do NOT accept requests if the acute client has already started any prescription drugs, is currently hospitalized or currently under a doctor's or licensed practitioner's directed care.

ACUTE INQUIRY FORM

First and Last Name

First and last name of person submitting form

Email

Email of person submitting this form.

Check for accuracy! This form will only submit with a valid email address.

Name of Person for Care
Age of Person for Care
Your Complete Mailing Address: Include all: Address, City, State, Zip Code.
Phone(s)

Please provide your home, work, and/or cell phones.

Best Time(s) To Call Please provide best times to call, if we need to reach you by phone.
Have you ever used homeopathy before? If YES, please give the NAME of your most recent Homeopath below.


If NO, write N/A.

TYPE OF ACUTE

Please briefly describe this acute in 100 words or less.

Give us the basic details for this acute. 

Were you  REFERRED to us?

If you are a REFERRAL, please give the name of the person who referred you.

If none, write N/A.

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This Acute Inquiry Form is tested regularly and is always working.
If it is not working for you, you have missed filling out a field.

Your information is always kept private and confidential.

By submitting this Form, you give Homeopathy for Women, it's Director and/or any of its Associated Homeopaths permission to contact you by phone, skype and/or email.  You will be contacted as promptly as possible.

If you have trouble submitting or seeing the above image, refresh your browser and retry.  Be sure to copy the image above exactly.  After 2 attempts, if you still have technical difficulty submitting this Form, please email us the contents requested in this form to: tech@HomeopathyForWomen.org

Please submit only once.

Thank you!

This Acute Inquiry Form is copyrighted 2008 - 2013 by Homeopathy For Women. 
All rights reserved.  No part of this Form or the on-line reporting system may be copied, reproduced digitally or in print without our written permission.

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Homeopathy For Women provides Classical Homeopathic Care for Women, Children and Families. 

Empowering Women and Their Families in the Homeopathic Lifestyle!