First Name: *

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Last Name: *

Date of Birth: *

Address: *

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Emergency Contact:

First Name: *

Last Name: *

Address: *

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Present Medical Condition(s): *

History of Medical/ Surgical Condition(s): *

What Medical/ Pharmacological method used in the past: *

Describe medical condition(s) and other details requiring the use of herbs: *

Type of Pain (eg: Chronic, Nerve, Arthritis): *

Allergies: *

Progression of current condition since it started: *

Have you used herbs in the past? *YesNo

Does your present condition affect your daily life or work? *YesNo

Describe: *

By submitting this form, you understand that herbs certification is self-pay service and it is NOT covered by insurance. You understand that all payment are due at service and are non-refundable.

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