General Order Form

Section 1: Contact Details
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Section 2: Ancient Origins Medicinals Products

Use this section to order any items from our line of high-quality, hand-crafted herbal products.
Item 1:
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50ml100ml250ml500ml
Name of tincture:
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For 5+ please contact us for availability
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100g
Name of tea:
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50 capsules
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50 capsules50g powder100g powder
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25 capsules50 capsules
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50mg100mg150 mg200mg
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Quantity:
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50mg100mg
Name of cream:
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2oz4oz
Name of spray / syrup:
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Item 2:
Select product type:
Select amount:

50ml100ml250ml500ml
Name of tincture:
Quantity:
For 5+ please contact us for availability
Select amount:

100g
Name of tea:
Quantity:
For 5+ please contact us for availability
Select amount:

50 capsules
Name of capsules:
Quantity:
For 5+ please contact us for availability
Select amount:

50 capsules50g powder100g powder
Select variety:
Quantity:
For 5+ please contact us for availability
Select amount:

25 capsules50 capsules
Select dosage:

50mg100mg150mg200mg
Select variety:
Quantity:
For 5+ please contact us for availability
Select amount:

50g100g
Name of cream:
Quantity:
For 5+ please contact us for availability
Select amount:

2oz4oz
Name of spray / syrup:
Quantity:
For 5+ please contact us for availability
Item 3:
Select product type:
Select amount:

50ml100ml250ml500ml
Name of tincture:
Quantity:
For 5+ please contact us for availability
Select amount:

100g
Name of tea:
Quantity:
For 5+ please contact us for availability
Select amount:

50 capsules
Name of capsules:
Quantity:
For 5+ please contact us for availability
Select amount:

50 capsules50g powder100g powder
Select variety:
Quantity:
For 5+ please contact us for availability
Select amount:

25 capsules50 capsules
Select dosage:

50mg100mg150mg200mg
Select variety:
Quantity:
For 5+ please contact us for availability
Select amount:

50g100g
Name of cream:
Quantity:
For 5+ please contact us for availability
Select amount:

2oz4oz
Name of spray / syrup:
Quantity:
For 5+ please contact us for availability
Section 3: Re-order a Custom Herbal Tincture

*This section is only for patients of Ancient Origins Medicinals or patients of other practitioners who have previously submitted your tincture formula(s) to us on your behalf. If you are unsure whether this applies to you, please contact your practitioner.
This formula has been prescribed to me by:

Megan WaddyAnother qualified health professional (please ensure the practitioner has already submitted the formula to us on your behalf).
Formula #1
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50ml100ml250ml500ml1L
Name of tincture:
Formula #2
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50ml100ml250ml500ml1L
Name of tincture:
Section 4: Additional Comments / Notes
Should be Empty:

Section 1: Contact Details

Section 2: Ancient Origins Medicinals Products

Item 1:

Item 2:

Item 3:

Section 3: Re-order a Custom Herbal Tincture

Formula #1

Formula #2

Section 4: Additional Comments / Notes