test form – emery herbals

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
Name
First Last
Shipping Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email*
Birth Date
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?
- Yes
- No
Please list any outstanding health concerns and any other information regarding your current wellness you wish noted.
Who referred you to our website?