Compounding Apothecary Request form for Practitioners
This form is for practitioners who would like MXED GREENS to fill herbal formulas for their clients. 
If you are looking to have a formula filled for yourself, please use our other google form "Compounding Apothecary Request form for Clients."
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Email *
I certify that I have read over and communicated to my client the MXED GREENS sliding scale + shipping information as explained HERE. You + your client will receive an email to confirm the request was received, and once the invoice for the herbs + shipping (if applicable) is paid for (via paypal or venmo), your formulas will be filled. 
If we are out of an ingredient in your formula request, we can suggest substitutions. 
 *
Your name + contact info *
Client name: *
Client contact email *
How will your client get their herbs? *
If you selected "mail," please provide a shipping address for your client
Formula Request: 
1. Please specify Extract, Bulk Herb, or Powder
2. Ratio of Ingredients (in parts or percentages). Extracts are assumed to be tinctures; please specify if any ingredients are glycerites.
3. total volume requested in oz
4. Any dosing instructions to be written on bottle (~10 works max) or bulk herb bag (no word limit)

Examples:
1. Extract
2. 2 skullcap, 2 passionflower, 1 chamomile glycerite
3. 5 oz
4. take 1/2 tsp 30 mins before bed, 1/2 tsp at bedtime

1. Bulk Herb
2. 2 tulsi, 1 gotu kola, 1/2 peppermint
3. 2 oz
4. 1  TBS/8 oz hot water, steep 10 mins. drink 1 quart or 4 cups daily.
 *
Additional Formula Request
 
1. Please specify Extract, Bulk Herb, or Powder
2. Ratio of Ingredients (in parts or percentages). Extracts are assumed to be tinctures; please specify if any ingredients are glycerites.
3. total volume requested in oz
4. Any dosing instructions to be written on bottle (~10 works max) or bulk herb bag (no word limit)
Additional Formula Request
 
1. Please specify Extract, Bulk Herb, or Powder
2. Ratio of Ingredients (in parts or percentages). Extracts are assumed to be tinctures; please specify if any ingredients are glycerites.
3. total volume requested in oz
4. Any dosing instructions to be written on bottle (~10 works max) or bulk herb bag (no word limit)
Additional Formula Request
 
1. Please specify Extract, Bulk Herb, or Powder
2. Ratio of Ingredients (in parts or percentages). Extracts are assumed to be tinctures; please specify if any ingredients are glycerites.
3. total volume requested in oz
4. Any dosing instructions to be written on bottle (~10 works max) or bulk herb bag (no word limit)
Thank you for submitting your order!
Once received, your client will receive an email (you will be cc'd) confirming their order and asking them to respond with the amount they would like to pay on the sliding scale and whether they would like to pay via venmo or paypal. Once payment is received, the formula(s) will be filled and shipped. We respond to emails and pack orders during open hours on Thursday and Saturdays, and ship on Fridays and Mondays. 
- Tasha, MXED GREENS' Clinical Herbalist
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