Liquid Herbal Request Form
Practitioner Full Name
First Name
Last Name
Clinic Name
Practitioner email
Patient Full Name
First Name
Last Name
Patient Contact Number
Please enter a valid phone number.
Patient Email Address
example@example.com
Patient Shipping Address (if posting)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What size bottle would you like?
25ml ($18), 100ml ($30), 200ml ($55), 500ml ($110). Surcharges apply for premium herbs.
What is the dosage? Include any specific dosing instructions.
e.g. 7.5ml twice daily after food.
Please write out your herbal tincture with the exact amount of herb you would like in the bottle (refer to our Dispensary list located on our website). Patients see below
Eg. If it is a 500ml bottle the total amount above should equal 500ml. If you are a patient, please submit script at bottom of this page.
Is the script to be express posted ($16 + GST) or picked up? Our herbal dispensary is open to the public on Fridays 1-4pm, Saturdays 9-5pm and Mondays 10-1pm. Mid week collection times can also be arranged by appointment.
If you are a practitioner please upload a copy of your Association Membership (only if this is your first time ordering from us). If you are a patient please upload your script here.
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