Client Forms
If you are interested in setting up an appointment with one of our practitioner, please fill out one of our secure, HIPAA-compliant online health intake and credit card information forms as appropriate to your situation.
CHOOSE THE FORM APPROPRIATE TO YOUR SITUATION
Please choose from one of the following options for secure, private online intake forms:
- Homeopathy Quick Start Form – (For minor illnesses or health problems, NOT related to Autism, PANDAS or Developmental Disorders)
- Sequential Homeopathy for Autism, ASDs, PDD-NOS, Aspergers, PANDAS, Learning and Developmental Disorders
- Download the GUIDE to creating a TIMELINE (which will be required for Sequential Homeopathy)
- Need to securely upload a timeline, photo or test results? Click here for a convenient and secure upload system.
- Update or add a Credit Card payment method HERE
- Click HERE: Relief and Support Programs Form to order:
- Autism Relief & Support Program
- Airborne Allergy Relief & Support Program
- Detox & Immune Support Program
- Sinus Relief & Support Program
- Urinary Tract Relief & Support Program
On the interactive form, please check the Relief & Support Program you are ordering.
Still have more questions? We offer a scheduled, discounted 30 minute “Discovery” consultation for adults/general health or a “Discovery” Consultation for ASDs/PANDAS/Developmental Delays with one of our homeopaths for $150. $50 will be credited towards an initial consultation.
At the end of the health form you will be able to proceed to the secure credit card information form.
We can only accept credit cards drawn on a USA bank, and with a USA billing address.
Even if you live outside the US we can still help you/your child!
We have clients in many countries worldwide.
Please choose one of the above options that pertains to your situation, and click below for instructions and payment options for international clients. We have been successful around the world with dozens of clients!
International Client Agreement – all Non-USA clients must read and sign.
Health information security
We also request that you send us a copy of your child’s original vaccine record and some photographs from birth, pre-regression (if regressive autism), post-regression and current.
Please fax (713-366-8710) or mail these items to our office. If you choose to email them, be aware that email is not secure, and you assume all risk for your/your child’s personal health information security.
Once we have received completed forms, records, photos and payment information, we will call you to set a convenient appointment.
Note: For any child under age 18, or a disabled adult, we must have permission from, and signatures of all custodial parents or guardian adults received in our office in order to provide consultations.
REMINDER
Please read the forms packet information carefully and include all requested materials and information — and ensure all information is legible and correct. Requested items may be:
Faxed to 713-366-8710 or
| Mailed to: | Homeopathy Center of Houston Attention: New Client Intake 1880 S. Dairy Ashford Rd. Ste 230 Bldg 2 Houston, Texas 77077 |
Do NOT send credit card information, nor health information via email. Please either fax or mail your information to best ensure privacy and security of your credit card and personal health information. Information sent by email is sent at client’s own risk. Please be safe with your information!
Once we have received all requested forms, appropriate signatures, photos and records, we will contact you to set your initial appointment. We look forward to serving you!
For more information, please explore our website further or follow us on Facebook to learn of new articles as we add and expand our articles on the wonders of homeopathy! Have more questions?
Call us at 713-366-8700. We are here to help you on your way to health-naturally!
