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) tea pillgranuleraw Quantity (e.g. bottle, dose, gram)(required) Refills (Refills are for current potency only, change of potency requires a new prescription) 0123456789101112 Patient Instructions (required) ____________________________________________________________________________________________________________________ Delivery Method (required) PickupMail Notes to Medicinary Payment Method (required) Bill my card on fileBill patient card on fileBill directly to patient