Here you can find the forms necessary to begin your diagnosis and treatment, or order herbal prescriptions.
NOTE: If you are interested in becoming a patient of Eastern Harmony Clinic please visit our New Patients page for important information. You will also need the appropriate forms below before your first visit.
Downloadable Forms
Below are links to forms that you can download, print, and fill out. You can then either fax or mail the forms to the clinic in advance of your appointment with Eastern Harmony Acupuncture & Herbal Clinic. Again, this is not affiliated with Dr. Randine Lewis. For information on the programs and services offered by Dr. Lewis, please visit www.thefertilesoul.com.
The forms listed below are set up as Portable Document Format (pdf)* files. To view and print these files, you will need the FREE Acrobat Reader browser extension or application from Adobe. See below for a link to download Acrobat if your browser does not already include this extension.
Please note: clicking on the links below will open a new window to load the form and/or launch the Adobe Acrobat Reader application. This window will remain open behind the new one. If a new window does not open, and you are asked to save the file, then you do not have the Adobe Acrobat Reader plug-in installed for your browser. Installing the plug-in (see below) will allow you to view and print all PDF files directly from your browser window.
If you have any trouble downloading and printing our forms, they are also available at our office. You may either pick them up, or contact us by phone or email if you would like them mailed to you, or fill them out at our office before your first visit.
| Complete set of forms for Women Patient Information Medical History Health History Women's Fertility History |
ehformsf.pdf |
| Complete set of forms for Men Patient Information Medical History Health History Men's Fertility History |
ehformsm.pdf |
| Separate Forms | |
| Patient Information Form | ehformpi.pdf |
| Medical History Form | ehformmh.pdf |
| Health History Form | ehformhh.pdf |
| Men's Fertility History Form | ehformmf.pdf |
| Women's Fertility History Form | ehformff.pdf |
| Women's Body Temperature Form | bbtlongf.pdf |
| *Requires Adobe Acrobat Reader Download FREE here |
 |
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Eastern Harmony Acupuncture & Herbal Clinic
Phone: 713/529-1610
4611 Montrose Blvd, Suite A201, Houston, TX 77006 (See Map)
email: info@easternharmonyclinic.com
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