Practitioner Order Form
503-206-4235
info@wildishpdx.com
* Required
Email address
*
Your email
Practitioner Information
Name
*
Your answer
Phone Number
*
Your answer
Patient Information
Name
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Order Information
Title Of Formula
*
Your answer
Type
*
Tincture
Capsule
Tea Blend
Oil
Other:
Formula (Types of Herbs + Ratios)
*
Your answer
Size / Amount (in ounces)
*
Your answer
Dosage
*
Your answer
Refill(s)
Your answer
Additional Notes / Comments
Your answer
Delivery Method
*
Local Pick-Up (3327 SE Hawthorne Blvd, Portland OR, 97214)
Shipping (Calculated amount will be added to invoice)
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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