Use TOPPLE10 at checkout to receive 10% off your first order. Clinic RE-OPEN Monday 12th April 21. Closed on Bank Holidays. School Holiday Appointments, Please Contact Me For More Information Re Opening Hours

Suffolk Elderberry Care Form

Name

Date of Birth

Address

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?

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).

Name

Date