Formula Request

Complete the form below to request a custom herbal formula. We'll send an automatic email to the client requesting payment information and approval.

Client:
Name:
Phone:
Email:	A copy of the formula will be emailed to this address
Address:
City:
State:
Zip:

Practitioner:
Name:
Phone:
Email:	Email a copy of the formula to this address
Address:
City:
State:
Zip:

Herbs	Parts

Parts are by: Volume (tsp) Weight (g)

Take × day for days.

Take with .

Note: Capsules are approximately 0.23 tsp.

Breakdown:	tsp	g	$
Herb Cost (+3% extra*):
Making fee (0 herbs, 30 days):
Capping fee ( capsules):
Cost of capsules ($0.05 per):
FORMULA COST:
* 3% extra is added to ensure the client has enough herb to complete the dosage course. Sales tax, if applicable, will be calculated at purchase time.

Other instructions:
Notes:
Refills Approved:	After final refill, client should re-assess with practitioner.

Thanks

Thanks for submitting your formula! We will reach out to the client soon about billing and completion.

(this will automatically pre-fill the same client & practitioner details)