Order Form - Custom Herbal Blends
Thank you for reordering the customized blend formulated by Innergy Medical Group. If you have any questions or concerns, please email Info@innergymedicalgroup.com
Email address *
First & Last Name *
Date of Birth *
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Please provide the name of the Custom Herbal Blend you would like to reorder. *
What size would you like to order? *
Desired pick up date *
By checking YES, I acknowledge that I have not started a new prescription medication. I understand that if I have, it is up to me to share this information with Carmen Adams, RH(AHG) & CHN. *
If you have started a new prescription medication, please provide the name and dosage.
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