Practitioner Order Form

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971-808-8093
info@wildishpdx.com

Email *

Practitioner Information

Name *

Phone Number *

Patient Information

Name *

Phone Number *

Email *

Order Information

Title Of Formula *

Type *

Tincture

Capsule

Tea Blend

Oil

Other:

Formula (Herbs + Ratios) *

Size / Amount (in ounces) *

Dosage *

Refill(s)

Additional Notes / Comments

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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