REVIVE Ear Seeds Custom Kit Form
Custom Kits include a virtual visit, 2 custom protocols based on your health history, enough ear seeds for one month of treatment, and accessories to apply them. Once you submit your form, you will receive an invoice. Once paid, allow 2 business days for your kit to be made and shipped. You will receive a link to my virtual calendar to schedule a virtual visit to go over your treatment plan and instructions on how to apply your seeds. Prices include domestic shipping.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Mailing Address (for shipping your kit)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your main health concern at this time?
Tell me more about this. When did it start, what makes it better or worse?
Is there another specific health concern at this time? If so, tell me about it.
Check off if you have experienced any of the following in the last 90 days
Eye strain or vision issues
Dry eyes
Sinus congestion
Runny nose
Allergies (Seasonal)
Allergy to Stainless Steel
Hearing loss
Tinnitus
Sore throat
Dry mouth
Frequent colds
Thyroid issues
Headaches or migraines
Jaw pain or TMJ
Hot flashes
Night Sweats
Neck pain
Mid back pain
Rib pain
Low back pain
Chest pain
Cough
Asthma
Breast pain or issues
Acid reflux
Stomach pain
Lower abdomen pain
Constipation
Diarrhea
Gas or bloating
Diabetes
Low libido
PMS
Fatigue
Hip pain
Leg pain
Knee pain
Foot pain
Heel pain
Arm pain
Elbow pain
Wrist pain
Hand or finger pain
Arthritis
Liver or gallbladder issues
Hypertension
Hypotension
Hemorrhoids
Nausea or vomiting
Erectile dysfunction
Poor circulation
Heart disease
Cancer
Anxiety or depression
Insomnia
Currently Pregnant
Select Your Choice of Seeds
Stainless Steel ($45)
24K Gold plated ($50)
Vaccaria Fair Tone ($35)
Vaccaria Dark Tone ($35)
Titanium Hypoallergenic ($50)
Clear Swarovski Crystals and Stainless Steel includes Super Stay Adhesive ($78)
Clear Swarovski Crystals and 24K Gold Plated includes Super Stay Adhesive ($83)
Rainbow Swarovski Crystals and Stainless Steel includes Super Stay Adhesive ($78)
Rainbow Swarovski Crystals and 24K Gold Plated includes Super Stay Adhesive ($83)
None, I just want the custom protocols ($25)
By submitting this form, you are requesting a custom virtual ear seeds consultation and kit. You agree to follow all instructions provided, including but not limited to how to apply and aftercare. You acknowledge that ear seeds are not a replacement for conventional medical care, and results are not guaranteed. Side effects may include, but are not limited to, sensitivity and skin irritation. I will not hold Colleen Conroy or REVIVE Ear Seeds and Acupuncture liable for any injury resulting from ear seeds use. Print name in box below to consent to receive ear seeding services.
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