For a Free Preliminary Consultation,

Call 1-888-869-2883

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New Patient Intake Forms

 

In order to create an effective treatment plan as well as select the most appropriate homeopathic remedy, we would like to request that you supply our office with the information detailed below.

The Intake Form can be sent through email as an attached document to the office at: homeopat@sover.net

Alternatively, it can be printed and mailed to our offices at:

Center for Homeopathy
220 Western Avenue
Brattleboro, Vermont 05301

In the case of children or persons otherwise incapable of writing themselves, the responsible person is requested to supply the information as best as possible.

We are aware that the amount of information requested is quite extensive. Please do not let it overwhelm or deter you, simply respond as best as possible and focus on what you consider the most relevant information pertaining to you. Again, please keep in mind that the more accurate and forthright the information, the more useful it will be to properly evaluate your case.

  • NOTE: TO DOWNLOAD THE FORM SUCCESSFULLY, PLEASE FOLLOW THE FOLLOWING STEPS:

    • Click the ‘Download the Form’ button below,

    • After it downloads and BEFORE beginning to fill it out, save the form to your desktop or any other location of your choice,

    • Fill out the form and SAVE again,

    • Then return it as an email attachment.