Practitioner Order Form
Email address *
Practitioner Information
Name *
Phone Number *
Patient Information
Name *
Phone Number *
Email *
Order Information
Title Of Formula *
Type *
Formula (Types of Herbs + Ratios) *
Size / Amount (in ounces) *
Dosage *
Refill(s)
Additional Notes / Comments
Delivery Method *
Stock Lists (bulk herb + tincture) + Membership Information
Fulfillment + Payment
* After filling out this information we will keep the order as a draft until payment is received. An email invoice will be sent to the patient, as well as a follow-up call. After payment, we will fill the order to be picked up or shipped. If the patient pays in-store, we will compound the order at that time.
* If you would like additional products/formulas to be in the same order - please fill out another form for custom formulas, or dictate all the needed information in the notes section.
A copy of your responses will be emailed to the address you provided.
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