Suffolk Elderberry Care Form

Name

First Name

Last Name

Date of Birth

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Email

Phone Number

Main reason for supplements

Symptoms

Medication / Other supplements you are currently taking?

Medical History (Awaiting tests, Surgery, Allergies or Serious Health Conditions)

Pregnant, Breastfeeding or Trying for Baby?

I am

Agree to terms

I understand that any herbal medicine/ supplements purchased or advice given is not a substitute for medical advice. I understand that my health is my responsibility and if I have any concerns about my health I will seek medical advice. Note: If you are currently receiving medical care and prescribed medication by your GP/Medical Practitioner/Consultant, please do not stop taking your medication without seeking the advice of your doctor(s).

I agree to the above conditions