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Health History & Wellness Intake

Please answer these questions fully and honestly. This info helps me create a care plan tailored to your unique constitution and wellness goals. Takes about 10–15 minutes.

Basic Info

Name

Date of Birth

Pronouns

Pronouns
A
B
C
D

Email Address

Phone Number

Are there any herbs you have interest in working with? (if this is for a custom formula, please describe the formula below and whether its a tea or tincture)