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Custom Tea Order Form
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Name
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Your answer
Age
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Your answer
Email address
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Your answer
Shipping Address:
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Your answer
Phone number:
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Your answer
What type of wellness concerns would you like to address with your custom tea blend?
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Your answer
What type of wellness concerns would you like to address with your custom tea blend?
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Your answer
What types of flavors would you like to include in your blend?
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Your answer
What flavors or herbs do you dislike?
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Your answer
What flavors or herbs do you like?
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Your answer
How often do you drink tea?
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Your answer
How do you drink your tea? (tea bag, infuser, kettle, etc.)
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Your answer
What types of teas do you currently drink?
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Your answer
Please list any allergies you have.
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Your answer
Are you seeing a doctor for your wellness concern? If so list any diagnosis that was given.
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Your answer
Please list any other health related issues that you presently have, or have had in the past.
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Your answer
Please list any family history of health related issues.
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Your answer
Are you taking any medication? If so, please list them
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Your answer
Are you taking any vitamins? If so please list them.
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Your answer
Can you commit to making tea every day?
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Yes
No
Is ease of preparation important to you?
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Yes
No
Additional comments
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