practitioner formula request form

If you are a practitioner and wish to have a formula filled for one of your patients, we are more than happy to assist you.  Please note that formula requests can take between 2-5 days depending on our own clinical patient demands.  Please plan accordingly with your patient so that they do not run out of herbs at an untimely instance. 

Please note that NO FORMULAS WILL BE FILLED WITHOUT A CREDIT CARD ON FILE.  We either need the practitioner's card on file if they are to pick up or we need your patient's credit card.  If your patient is paying and picking up, please encourage them to call us once you have submitted this to streamline the process. 

If you have any questions regarding your formula request, please feel free to call our office at 303-777-7891.  We will confirm that we have received your request. 

Practitioner Information
Name of Practitioner Prescribing Formula *
Name of Practitioner Prescribing Formula
Practitioner's Phone Number *
Practitioner's Phone Number
Patient Information
Patient's Name *
Patient's Name
Patient's Phone Number *
Patient's Phone Number
Formula Details
If YES...please complete next question below.
Please put your name for this formula or the purpose for which it is being used in this section. This will go on the label.
Please put your formula within this text box. Please include the number of grams on the left followed by the name of the herb. Also include the total number of grams at the end and the number of grams you wish to prescribe per dose and the number of times per day.
Collection/Pick Up of Formula Information
Do we either have practitioner's credit card on file if practitioner is picking up or do we have the patient's credit card on file? If we do not or you are unsure, please phone us at 303-777-7891 to let us know. NO REFILLS WILL BE PROCESSED WITHOUT A CREDIT CARD. All formulas are tailor made for the individual and once it is created, it can not be returned to our inventory. We will not begin this order until a secure credit card has been received/confirmed by our office.
Ship to address
Ship to address
If we are shipping this to the patient, pleas provide the address here. Please note that there will be a minimal shipping charge for this service as well.