Consultation Request Form

Call (206) 328-2828 or

13256 NE 20th St. STE 3A Bellevue, WA 98005

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Please use the form below to provide as much information about yourself as possible for the herbalist to review.

It is important to email your pictures of your face and tongue Here after submitting the form for more accurate evaluation....unless you are already scheduled to see the herbalist in person within 5 days or so.

First Name *

Last Name *

Birthday *

i.e. 08-26-1970

Gender *

Email *

Phone *

Street Address *

City *

State or Province *

i.e. WA, CA, NY

Postal Code *

Country *

i.e. United States, Canada

Tell us about
your health concerns *

Describe the history of
your medical Conditions
and surgeries*

List of medicattion and
dietary supplements *

Best time to contact you *

i.e. Between 3pm-5pm

How did you hear about us? *

	Friend & Family
	Online Search
	Advertisement

Referred by (if any)

Important! We would like to thank him or her for referral.

I have read the disclaimer *

Yes

Read the disclaimer Here.