Payment Form

Below is the client payment form. The mailing address section is optional. Fill this out if you anticipate receiving an herbal formula/product. This can always be changed later. Also, a credit/debit card can be used without a PayPal account. Once the payment is submitted you’ll receive an auto-email thank you note (sent to your email address). If you did not receive the thank you note, check your spam/junk folder.

Name *

Phone *

Email Address *

Mailing Address (for herbal formula mail out)

Apartment, suite, etc

City

State/Province

ZIP

Select

Consultation, initial - $150

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