Full Name

Email Address

Mobile

Date of Birth

Postal Address (to send herbal formula)

City

Postcode

What is the reason for your formula? What is the reason for your formula? Cough Cold and Flu Anxiety Poor Sleep Constipation Diarrhoea Stress Reflux Other

If other, what?

What are the details of your symptoms (length of time, is it constant or sporadic etc...)

Do you have any pre existing conditions?

What medications are you taking? (Including anything you are taking sporadically)

Please check the boxes that apply to you. Are you...? Please check the boxes that apply to you. Are you...? Pregnant Breastfeeding Have high blood pressure Have a heart condition Using recreation drugs Highly sensitive

Have you taken herbal medicine before? Have you taken herbal medicine before? Yes No

Do you have any allergies to anything? Food, medicines, environmental?

I declare that everything in this form is accurate to the best of my knowledge I declare that everything in this form is accurate to the best of my knowledge Yes