test form

Customer Intake

  • Due to Health Canada regulations we require the following information to be on file prior to dispensing any herbal or essential oil formulation. Thank you for your time in filling out our intake form. Please note that all information submitted will be held in confidence.
  • In order to serve you better, please ensure that you fill in all fields prior to submitting. Thank you.

  • All inquiries regarding this form should be sent to: Colleen at Emery Herbals
  • Date Format: MM slash DD slash YYYY
  • Please list any medications, supplements and/or herbal formulations you are currently taking:
  • Are you currently pregnant or trying to conceive?
  • Please list any outstanding health concerns and any other information regarding your current wellness you wish noted.
  • Who referred you to our website?