TCM FormulasTM
Personalized Chinese Herbal Formulas

Student Powder Order For Self

	Step 1: Who and Where
	Intern:	Your Phone #:	Formula #:
			(For quicker refills)
	If you are ordering a refill, do not use this form; instead, consult the help screen for quicker, easier methods.

	Shipping Information	Street Address	City
	Delivery to Me ($4.95) Pickup at PCOM SD	State	Zip code:

	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