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Full Name (First & Last)
Contact Info: Best way to contact you. (Phone/Email)
Mailing Address (Best address for me to send your samples)
Top 3 Ailments/Health Concerns
Pain (Muscle, Joint, Tissue)
Stress Management (Anxiety, Grounding, Depression)
Respiratory Support (Asthma, Cough, Sore Throat)
Weight Management (Protein, Greens, Fiber, Cravings)
Sleep Support (Relaxing, Insomnia)
Digestive Support (IBS, Heart Burn, Acid Reflux, Upset Stomach)
If you wish to include any additional information regarding your ailments/health concerns, please explain below so that I can be more specific with your samples and information!
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