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.Format: (000) 000-0000.
Preferred Contact Method
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)

Other
3. Secondary Preferences
Flavor Profile Preferences

Other
Preferred Preparation Form

Other
4. Current Health & Lifestyle
What are your lifestyle habits? (Select all that apply)
Energy levels
Digestion
Sleep Patterns
Stress Levels
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
Packaging preference

Other
What are your goals for this consultation?
Any extra details you'd like me to consider?
Preferred Method of Consultation
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
Date

MonthDayYear
Date
Signature
Should be Empty:

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