TCM FormulasTM
Personalized Chinese Herbal Formulas

Practitioner Powder Order Form

	Step 1: Who and Where
	Practitioner:	Patient:	Formula #:
			For quick refills

	Shipping Information (if not to your office)	Street Address	City
	Delivery to Patient ($4.95) Single order to my office ($4.95) Delivery with other products to my office ($2 per item)	Zip code:	Patient Phone:

	Step 2: Duration and Daily Dosage

	The formula should last:	days
	The daily dosage is:	scoops	times per day
	which equals a total of:	g per day (automatically calculated).


	Step 3: Herbal Formula
Enter the original herbal formula (use as many spaces as you need and leave the rest blank) with their original dosages
Herb Formula Name: ( for quick refills!)

Herb		Dosage	Converted Dosage
1		g
2		g
3		g
4		g
5		g
6