Patient Health Questionnaire PHQ9

Name

First NameLast Name

Date

MonthDayYear

Please note that in accordance with Health Canada's new regulations, the sale of all teas now require a consultation prior to purchase.

Our complimentary consultations are conducted via phone or email for your convenience.

All customers are required to fill out the form below, and we will accommodate your request to the best of our ability.

For customers seeking custom formulations, please utilize this same form.

Once you have filled in this form you do not need to do another one for future purchases within the same year.

What is the main reason for the consultation

Purchasing TeaGeneral information

How would you prefer we do the consultation?

emailtextphone

Phone Number

Please enter a valid phone number.

Email

example@example.com

In brief words please share what you are looking to get support with? *

Are there specific teas or herbs you are interested in or looking for?

Do you have any underlying health conditions? If so, please list.

Are you taking any prescription medications? If so, please list.

Do you have any allergies? If so, please list.

Thank you for taking the time to fill out this form. We will get back to you within the next 24-48 hours to best support your request based on the information provided.

Discretion is important to us. We will never share your personal information with any third party without any written request/consent to do so. We look forward to getting to know you.

Intake & Liability Form

I understand and acknowledge that these teas and herbs are intended for general well-being and are not meant for the purposes of treating any disease or health condition.

I herein state that I am not currently involved in psychotherapy. I have not recently been hospitalized for mental illness, and I am not currently taking any psychotropic medication.

I further waive, release and discharge Georgina Cyr from any and all liability for, including but not limited to, my disability, death, personal injury, indemnifying, holding harmless and pledging no legal action towards said persons.

By signing my name below, I willingly agree to release, Georgina Cyr, and/or the Facility in which the teas are made and sold from any said claim.

I have read and understand this release form, and by my signature consent.

Signature

Customer Health Questionnaire