2020 AV Formula Order Form
PLEASE NOTE:
• You must be a current or past patient to purchase.
• Contact the office if you'd like to become a patient: (818) 348-9973, ext. 1.
• 3-bottle maximum per order, per patient.  
• Cost $90 each (plus tax & shipping)
• Orders will be handled on a first come first serve basis while supplies last.  
• Our office is working with limited staff your patience is greatly appreciated.

Adres e-mail *
If ordering for more than one patient in a household, please submit a separate order (available after submission of this form).
Patient First Name: *
Patient Last Name: *
E-mail: *
Phone: *
Which of our herbalists have you seen in the past?
Odznacz
Approximate date of last visit:
2020 Antiviral Formula Order (3-bottle limit per order):
1 Bottle
2 Bottles
3 Bottles
Prevention
Mild Symptoms
Mild Symp-G6PD patients
Recovery
A spoon is provided with herbs. However, if you prefer capsules, self-fill capsules are available @ $6 per bag (approx. 100 capsules).  Number of bags requested?
Is your credit card on file with our office?
Last 4 digits of credit card on file:
Orders without known payment method will require phone confirmation.
Billing Address Street:
Billing Address Apt./Unit:
Billing Address City:
Billing Address State:
Billing Address ZIP Code:
Shipping address is same as billing address:
Odznacz
SHIPPING Address Street:
SHIPPING Address Apt./Unit:
SHIPPING Address City:
SHIPPING Address State:
SHIPPING Address ZIP Code:
Do you have any comments or questions for us?   If using PayPal or VENMO, please provide your contact information on that site/app.
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