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  • Herbal Consultation Intake Form

    Please Note: This detailed intake form has many questions that may or may not pertain to your condition. This questionnaire is searching for potentially undiagnosed conditions and connections between ailments. Please feel free to answer only those questions you feel are important to your health concerns, or take the time to finish the full form. Any questions that you would rather discuss in person can be saved for future discussion. The price for an herbal consultation is $150.00 which includes a complete wellness workup and a wellness product. Please make this payment on the Rafiki Beauty and Wellness website.
    • Personal Information 
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    • Diet, Nutrition and General Health Practices 

    • Fill in the blank:
      I drink cups of water each day.

    • I sleep hours each night on average.

    • I exercise for hour(s), times per week.

    • Medical Information 
    • Payment and Submission 
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    • Please purchase the Herbal Consultation Payment via the website.

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