International Homeopaths For Autism [IH4A]

Referral Request Form

Your name [for contact] *

I am the *

non-homeopath

homeopath

Phone *

Facebook Profile URL [for easy contact]

Country *

Email *

If there is a member of IH4A you think you'd like to work with name them here:

Patient's full name *

Patient's Date of birth *

Patient is *

Female

Male

Other

Diagnoses [if any] *

Timezone of person consulting *

What recurrent infections has the patient suffered? *

List the issues you want treatment for, with the most important at top. [Also, show severity out of 10]. This information is very useful in helping me meet your needs. *

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10/10 = the worst it can be

Date of patient's last high fever *

Please, upload any relevant test results you wish to sent [ie, ATEC, OAT, HTMA.]

ATEC, OAT, Hair mineral analysis [HTMA], etc.

Files will be held securely as per our privacy policy. By uploading you are agreeing that you have read the privacy policy and are consenting to Wren Lloyd and International Homeopaths for Autism holding these files securely.

Make a Wishlist of gains you'd like to see from treatment [start with the most important]. This info is very useful in helping us understand your needs. *

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Terms & Conditions Agreement *

I have read and agree to abide by Wren's terms of service as laid out in the link below, particularly ...

~ I'm aware Wren & the homeopaths of IH4A are not medical doctors & are not offering medical treatment.

I Consent to Receive emails & occasional marketing communication from Wren Lloyd. I can unsubscribe at any time.

Signature

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The person filling the form should please sign within the box