Herbal Blend Intake Form

Herbal Blend Intake Form

Please fill out this form to help us understand your health needs and concerns. Your information will be kept confidential.
1. Contact & Order Details
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Preferred Contact Method*

PhoneEmail
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
2. Primary Wellness Goals
Primary Wellness Goals (Select up to 3)*

Better sleep / relaxationStress relief / emotional balanceIncreased focus / mental clarityEnergy & vitalityDigestive healthImmune supportHormonal balanceSkin healthRespiratory supportOther
3. Secondary Preferences
Flavor Profile Preferences*

Mild & soothingSweet & floralSpicy & warmingBitter / strong herbalCitrusy & refreshingOther
Preferred Preparation Form*

Loose teaPowderTinctureCapsulesOther
4. Current Health & Lifestyle
What are your lifestyle habits? (Select all that apply)

Regular ExerciseBalanced DietSmokingAlcohol ConsumptionStress Management TechniquesOther
Energy levels*

LowModerateHigh
Digestion*

SensitiveNormalConstipatedLoose Stools
Sleep Patterns*

Trouble falling asleepTrouble staying asleepRestful sleep
Stress Levels*

LowModerateHigh
Typical daily caffeine intake (cups)*
Water intake (cups)*
5. Safety & Medical Questions
Do you have any allergies to plants, herbs, spices, or foods? If yes, please list any and all allergies.*
Are you currently pregnant, nursing, or trying to conceive?*
Are you currently taking any prescription medication? If yes, please list all medications.*
Do you have any diagnosed medical conditions? If yes, please provide all medical conditions.*
Have you had any adverse reactions to herbal products in the past? If yes, please detail your experience.*
Do you have any special restrictions? (e.g., caffeine-free, gluten-free, vegan)*
6. Dosage & Packaging Preferences
Daily servings desired?*
Preferred package size*

1 week supply2 week supply1 month supply
Packaging preference*

Glass jarCompostable pouchOther
What are your goals for this consultation?*
Any extra details you'd like me to consider?
Preferred Method of Consultation*

In-PersonPhoneVideo Call
8. Safety Disclaimer & Consent

I understand this custom blend is not intended to diagnose, treat, cure, or prevent any disease. I will consult my healthcare provider before starting any new herbal regimen, especially if pregnant, nursing, taking medications, or having medical conditions.
I agree to the above terms*

I Agree
Date

MonthDayYear
Date
Signature

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Herbal Blend Intake Form

1. Contact & Order Details

2. Primary Wellness Goals

3. Secondary Preferences

4. Current Health & Lifestyle

5. Safety & Medical Questions

6. Dosage & Packaging Preferences

8. Safety Disclaimer & Consent