Complimentary Mini Consult Form for Herbs Please enable JavaScript in your browser to complete this form.Name *FirstLastWhat is the main reason for the mini complimentary consultation?Purchasing Online Herbal Tinctures, Oils, Creams, CapsulesCustomized FormulasGeneral InformationComment or MessageHow would you prefer we conduct the consultation?PhoneEmailZoom (zoom consultations are prebooked by appointment)Email *Phone Number and Area Code *AddressAre the herbs you are looking for prescribed by a healthcare practitioner?*YesNoIs there any possibility that you might be pregnant? *Yes - I am currently pregnantNo - by checking this box I confirm that I am not pregnantUnknownIn brief words please share what you are looking to get support with? Are there specific herbs (or herbal products) you are interested in or looking for?Do you have any underlying health conditions? If so, please list.Are you taking any prescription medications? If so, please list.Do you have any allergies? Are you allergic to any medication? If so, please list.Have you every suffered from a serious illness or injury?Waiver *By clicking here, I confirm that all the details above are true. I understand that accurate details will help to ensure that I receive the best health care possible.I understand that the mini consult offered are not a substitute for a complete medical diagnosis provided by a medical doctor.Thank you for taking the time to fill out this form. We will get back to you within the next 24-48 hours (Monday to Friday) in order to best support your health goals based on the information provided. Discretion is important to us. Alchemy & Elixir Health Group will never share your personal information with any third party without any written request/consent to do so. We collect this information in accordance with Health Canada regulations in order to provide you with your desired herbal medicine products. We look forward to getting to know you.Submit
