1. What symptoms are you feeling? How long since they started and? Have you experienced them in the past *

2. What medication are you taking, if any? Please include prescribed or purchased medication and alternative therapies. *

3. Has a Health Professional recommended that you use this product on this occasion? *

4. Do you have any other health conditions or allergies, including pregnancy/breastfeeding? *

5. Any other information you feel we need to know? Do you have any other questions you would like answered? *

I agree: I am over the age of 18 years old (if purchasing this product for someone under the age of 18, I have consulted a healthcare provider and am legally able to act on the minors behalf). I am buying this product for myself. Agree that my answers to the questionnaire are accurate at the time of purchasing this product. I will consume any Practitioner Only products in accordance with the product label, including the directions for use *

Thank you!

Thank you for completing the form. If required we will be in touch. Enjoy your product.

Have a great day!

Thank you!

Thank you for completing the form. If required we will be in touch. Enjoy your product.

Have a great day!

Practitioner Only Product

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