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: *
MM
/
DD
/
YYYY
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. *
Required
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.
FOR OFFICE USE ONLY

__ 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.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of uprootinglyme.com. Report Abuse