Product purchase form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastPhoneEmail *Are you currently taking any medications or supplements? Please provide a list.Do you have any known allergies or sensitivities to herbs, foods, or medications?Include allergies to herbs, foods, or medications What be any Do you currently have or have a history of the following conditions?Cardiovascular disease (e.g. hypertension, arrhythmia)Bleeding disordersKidney diseaseEpilepsy or seizure disorderAutoimmune diseasePregnancy or breastfeedingWhat symptoms or health concerns are you currently experiencing?How long have you experienced these symptoms?Less than 1 month1–6 months6–12 monthsOver 1 yearI understand this product is not a general consumer good, and is provided based on professional assessment. *YesThis product is offered as part of a practitioner-client relationship. Please complete the following questions to determine its suitability. By submitting this form, you agree to receive practitioner-guided recommendations.I understand that this form will be reviewed by a practitioner and I may be contacted before purchase approval. *YesSubmit
