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Adult Registration Form

Home > Adult Registration Form


Adult New Patient

Please allow 30 minutes to complete this detailed new patient form. Please fill out as thoroughly as possible and do not leave any fields blank. The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.


Medical History

Illness, Date, Hospital, Location.
Foods, pets, pollens, molds, chemicals, medications, etc.
Type, dosage, frequency.
Name, dosage, frequency.
Name, potency, frequency.

Do you use:

Tests:

Immunizations

Check the corresponding box if any of these options apply to you:

Men only

Women only

Personality and Preferences

Family History

Highlight all relatives with a history of this illness.

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      The information you provide here is kept private and confidential in accordance with Federal HIPPA Laws.

      Thank you!

      Tina Louise Buie

      Tina Louise Buie, CH, IBCLC, RLC is a Classical Homeopath.

      Now accepting new patients located in and around Fort Worth, Texas.

      Tina also works long-distance, by phone and by Skype.

      Contact Details

      • Phone: 503.877.4325
      • Email: tina@classichomeopath.com
      • Location: Fort Worth, Texas

      Recent Posts

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      Contact Tina

      • Phone: 503.877.4325
      • Email: tina@classichomeopath.com
      • Location: Fort Worth, Texas

      About the Homeopath

      As a graduate of the American Medical College of Homeopathy, Tina studied under the acclaimed author, physician and Homeopath, Dr. Todd Rowe. Her advanced education also includes extensive studies under other world-renowned Homeopaths including...

       

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      • Home
      • New Patients
      • Learn About Homeopathy
        • What is Homeopathy?
          • Advantages
          • Conditions
          • Remedy Sources
        • Additional Reading
          • History of Homeopathy
          • Resources
      • Patient Resources
        • New Patients
          • Adult Form
          • Child Form
          • Schedule an Appointment
        • Before your Consultation
          • Policies & Procedures
          • How to Prepare
        • After your Consultation
          • Antidotes to Avoid
          • Is the Remedy Working?
          • LM Potency Instructions
      • Contact
        • About Tina
        • Contact Tina
      • Blog
      • Testimonials
      • Policies & Procedures
      • My Account
      • Check Out

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