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Homeopathic Kit
Online Order Form

Please enter your Personal Details, Health Profile and Kit requirements below and click the send button at the end. Note: Fields marked * must be completed.

If you do not receive a reply within a few days please call us.

*Personal Details*

Gift voucher code (if you have received a gift voucher):
*Name :
*Postal address :
*Post Code / Zip Code :
*Country :
*E-mail :
*Telephone : (please include international dialing code)
Date of Birth :
Gender :	Male Female
Occupation :
Used Homeopathy Before?	Yes No

Health Profile


	Low/Poor		Medium		High/Good
Level of Health	1	2	3	4	5
Amount of Exercise	1	2	3	4	5
Energy Level	1	2	3	4	5
Thirst/Daily Fluid Intake	1	2	3	4	5
Anxiety Level	1	2	3	4	5
Sleep	1	2	3	4	5
Quality of Diet	1	2	3	4	5
Alcohol Intake	1	2	3	4	5

Alcohol units per week	units
Smoking	Smoker	Non-smoker
Height
Body Shape	Slim	Average	Overweight
Colouring	Dark	Fair
Diet	Veg	Non-Veg
Blood Pressure	High	Normal	Low


Food Preferred	1 2			3 4
Food Aversions	1 2			3 4
Body Temperature	Hot	Average	Cold	Clammy	Cold Extremities
Sweat	Yes	No	Location on body where you sweat the most?
Preferred Temp	Hot	Humid	Cool	Damp	Rain	Open Air
Preferred Environment	Sea	City	Forest	Mountains
Any serious health problems / hospitalisations / operations / accidents in the past 5 years?					Yes	No
If Yes, details:
Are you on any medication, treatment or other therapies?					Yes	No
If Yes, details: (name/dosage/type)

*Kit Fit*

Please click on the kits that best suit your current needs:
Travel	Mother & Child	First Aid	Cold & Flu
Stressbusters	Sports & Strains	Mix & Match	Other
Mini Kit	Please refer to the Directory of Homeopathic Kits to identify the Mini Kit of your choice. Mini Kit Type:
	Mix & Match / Other Details: If the kit of your choice is not already there in the maxi or mini format, then make up your own by listing the main areas/symptoms you would like to address e.g. jet lag, hangovers, indigestion and torn ligaments. Remember the mini kit is limited to four remedies. Call us on +44 (0)207 209 0490 to talk through your gift kit in more detail
Thankyou for your Order. Please check that your contact details are correct, especially your email address, then click the 'Send Order' button.

Remedy That! - Registered Homeopaths, offering Tailor-made Homeopathic Remedy Kits for your individual needs.