Cosmic Cures Consult Form

Cosmic Cures Consult Form
BIRTH CHART INFORMATION
Name
Pronouns
BIRTH TIME
DOB
Email
example@example.com
StateCityCountry at Birth
Tell me about whats going on in your world right now This helps me understand what kind of energetic emotional or physical support youre calling in Any goals intentions or areas of focus youd like me to consider
Please answer honestly SO I can safely tailor your blend. Your info stays confidential and sacred. Do you have any allergies (especially to herbs, alcohol, or plants)?
Do you have any allergies especially to herbs alcohol or plants
Are you currently taking any medications or supplements
Do you have any diagnosed health conditions physical or mental that I should know about
Are you pregnant trying to conceive or nursing
What do you hope this custom tincture will help you with? (check all that apply)
Something else (describe below):
Please read carefully and check each box to confirm your understanding and agreement before receiving your custom tincture:
SIGNATURE
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: