Practitioner Dispensary Form

Practitioner Dispensary Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number
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Practice*
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By signing below, I acknowledge that I have read the "Practitioner Dispensary Guidelines" in its entirety. I understand that no one associated with The Elderberry is a medical doctor, nor do they diagnose, prevent, or treat disease.*
We look forward to being of service!

The Elderberry

1917 Commonwealth Drive, Charlottesville, Virginia 22901

www.elderberryherbals.com

(434) 964-9376
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