Supplement & Herbal Formula Refill Request Form

Supplement & Herbal Formula Refill Request Form
We only fill herb orders Mondays and Thursdays. Supplement orders only go out once at the end of the month or you can order off our webstore any time.
Patient Name*
Herbal Formula or Product Requested (include pill count or we will order the largest bottle)
Is the formula or supplement working for you? Please explain.*
I will pickup at my next appointment.I will stop in during business hours and grab the bag with my name on it from the shelf under the water pitcher.Please leave in the hall, I will pickup outside of office hours. I understand that in the unlikely event my products are missing Geneva Acupuncture is not responsible to replace.Please mail to address on file. I understand additional for shipping apply.
I give Geneva Acupuncture LLC permission to run my credit card on file for the requested products.*

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We only fill herb orders Mondays and Thursdays. Supplement orders only go out once at the end of the month or you can order off our webstore any time.