Practitioner Wholesale Shipping Request Form
For health practitioners who currently have a wholesale account with us. For all other health practitioners wishing to place an order, please call 845 687 6211 to set up an account.
Email *
Practitioner name: *
Today's date: *
Practitioner phone number: *
Ship to Name and Address: *
Shipping email address: *
What email address should we send shipping notifications to? (We recommend the patient's email address)
Product 1. *
Product 2.
Product 3.
Any additional products:
What would you like us to do in the case of item/ingredient unavailability? *
Dosage instructions for patient:
Include NLHC patient handouts?
Any special shipping or billing instructions?
NLHC charges a flat $10 minimum shipping fee for any order. Orders that cost more than $10 to ship will result in a charge for actual shipping costs. *
Please double check your order before submitting.
Errors such as typos or lack of quantity of products requested will delay your order as we reach out to you for clarification.

__ Charge Wholesale
__ Make Product/Gather Product
__ Print Label
__ Pack
__ Ship

Date shipped:
A copy of your responses will be emailed to the address you provided.
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