Ginseng Sample Form

Name*

First NameLast Name

Date of birth*

Date

Email*

example@example.com

Phone number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?*

WebsiteWeb searchFriendOther

Are you over the age of 18?*

YesNo

Health History | Please check any of the following that applies to you*

Have you ever tried ginseng powder before?*

YesNo

Please agree to the terms and conditions*

I hereby agree to have a ginseng sample pack sent to my address given above.I understand and agree to the instructions of use and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.I understand that in rare occasions there are risks associated with trying a new food supplement. I further understand that in rare circumstances digestive disruption may occur.I agree to being sent any promotional material and added to the Ginseng Co. mailing list.