HERBAL SALES

Have your own herbal formula prepared
and mailed to you.

Choose from the extensive list of dispensing herbs for your own favourite recipe.
Only the best available extracts used,
Strongest 1:2 or 1:1 strengths
Herbal formulas are usually prescribed on the basis of a formal consultation. Where that has not occurred through this Practice the responsibility for the appropriateness of the formula rests with the orderer. Your formula will be checked for the safety of dosage. If you require advice on appropriate herbs for your condition contact by email. (a charge applies)

Herbal Formula FORM

This form may be used to order herbs and formula.
* Required fields

NAME:*
AGE:*
ADDRESS:
ADDRESS (cont):
SUBURB:
STATE (non US):
ZIP Code:*
COUNTRY:
STATE (US only):
TELEPHONE:
EMAIL:*
GENDER:

Do you require a quote on individual herbs only?

I require single herbs only.

Yes No

Pregnant/Breast Feeding:

 Yes No

ALLERGIES?

CONDITION?

Cost
100ml $19
200ml$35
500ml $80
Including GST. Plus postage and packaging.

Prices quoted in Australian dollars.

Fill in the Herb name and required amount as a percentage of 100%.
Total amount must equal 100%. Quantity xml. Times xml x times daily.

ID

Herb Name

Quantity x ml%

Herb A

Herb B

Herb C

Herb D

Herb E

Herb F

NATURAL REMEDIES:

Natural Remedies - I would like more information

Natural Remedies - I wish to purchase (list product type in comments section below)

Natural Remedies - I require a consultation

ULTRA LITE WEIGHT LOSS:

Ultra Lite - I require a consultation, please contact me by telephone to arrange a time.
Ultra Lite – I would like to find a closer practitioner (Aust. & NZ only).

IRIDOLOGY:

Iridology - I would like more information
Iridology - I require a consultation

CONTACT PREFERENCE:

I would like;
An Appointment
Telephone me
Email me
Post me a Brochure

COMMENTS?