Submit a Herbal Order

    Practitioner First and Last Name (required)

    Practitioner Email (required)

    Practitioner Telephone

    ____________________________________________________________________________________________________________________

    Patient Name (required)

    Patient Address (required)

    Patient Phone Number (required)

    ____________________________________________________________________________________________________________________

    Formula (required)

    Format (required)

    Quantity (e.g. bottle, dose, gram)(required)

    Refills (Refills are for current potency only, change of potency requires a new prescription)

    Patient Instructions (required)

    ____________________________________________________________________________________________________________________

    Delivery Method (required)
    PickupMail

    Notes to Medicinary

    Payment Method (required)