CBD Consult - Updated June 2021

Request for AGORA CBD Oil/Aromotherapy Consult/Custom Blend

Kindly fill out the fields below. Those indicated with an asterisk * are required fields
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Main Complaint*
Allergies*
Current/Problematic Medical History
Current List of Medications
Significant Social History
Schedule an Appointment-Wednesday or Thursday 9am-2pm
Preferred Date*

MonthDayYear
Date
Preferred Time*
I understand that I am paying for an aromatherapy consultation and/or custom blend and these services do not take the place of medical care. I also have read the attached information and understand that these statements are not approved by The Food and Drug Administration.
Pleases sign with mouse or touchpad*
Date*

MonthDayYear
Date
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Request for AGORA CBD Oil/Aromotherapy Consult/Custom Blend