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 *What product(s) are you interested in purchasing? *Hipsilo(A)Hipsilo(C)Digestion FormulaLiver FormulaMen's FormulaMind FormulaParasite FormulaSinus FormulaUT FormulaWomen's FormulaAre 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 medicationsDo 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? experienced have What How long have you experienced these symptoms?Less than 1 month1–6 months6–12 monthsOver 1 year Liability Acknowledgment By submitting this form, I confirm that the information I have provided is accurate to the best of my knowledge. I understand that: I accept full responsibility and liability for the use of any product I purchase. Any practitioner review or approval of this form does not constitute a diagnosis, prescription, or acceptance of risk. I agree to consult a qualified healthcare provider if I have any concerns about the safety or appropriateness of this product for my health. I have read and understand the above, and agree to the terms outlined. * Submit
