HillJilly Naturals Questionnaire

HillJilly Naturals Questionnaire

We’d love to hear from you! Please submit the form below and we will be in touch shortly.
What is your top health concern(s)?
Please list in order of greatest to least pressing if you have more than one.
What medications are you currently taking?
Please include all prescription AND over-the-counter medications
If you could replace prescription medication for herbal remedies, would you?

YesNoI’m not sure
Are you interested in growing your own medicinal herbs?

YesNoMaybe, but I need more information
Are you interested in learning how to make your own medical herbal remedies?

YesNoMaybe, but I need more information
Would you like us to contact you with more information?

YesNo
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
What is your preferred method of contact?

PhoneEmail
When is the best time to contact you?

Morning (before 12pm)Afternoon (before 5pm)Evening (after 5pm)Any time
Herbal remedies have a wide range of applications and powerful applications. You should always be under the supervision of a professional while utilizing herbal medicinal remedies. By signing below, you accept responsibility and acknowledge such.
Do you understand the above statement and agree?*

YesNo
Signature*

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