Custom Order Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Custom Order Form

Complete and submit this form if you would like to purchase our homeopathic remedy kits or if you are looking for specific homeopathic remedies. If we are unable to fulfill your order or if we have questions, we will contact you. After we receive your request we will send you an email with your total cost which must be paid via check / money order prior to shipping. Please include your order # on the check / money order. We only ship via USPS within the continental US. Once your payment is received we will process and ship your order as soon as possible. Larger kits & custom orders may take 2-3 weeks to ship. We are not in the office on weekends, if you send a custom order request on a weekend it will not be processed until the next weekday. If you have any questions, please contact us via email (orders@lotuswellnesscottage.com). Thank You!

Email *

Date of Order Request *

YYYY

Full Name *

Complete Address (Billing) *Please include apartment / unit number if applicable *

Name & Address - Shipping To (If different from above) *Please include apartment / unit number if applicable

Phone Number (best # to reach you) *

Individual Homeopathic Remedies

This should include any homeopathic remedies not listed below that you would like to request, include the remedy name, quantity of each remedy & potency (if applicable). We sell individual remedies in 1 Dram vials at $10/vial + shipping. If you are looking to refill a vial from a kit, please indicate the vial size in your request. Kit refills in 1/2 dram vials are $5/vial + shipping.

Homeopathic Remedy Kits

Include quantity requested in the "other" section. Pricing shown does not include shipping.

Homeopathic Emergency Kit - 6c Potency ($145.00)

Homeopathic Emergency Kit - 30c Potency ($155.00)

Homeopathic Emergency Kit - 200c Potency ($180.00)

Emergency Remedy Kit (PART 2) - 6c Potency ($145.00)

Emergency Remedy Kit (PART 2) - 30c Potency ($155.00)

Emergency Remedy Kit (PART 2) - 200c Potency ($180.00)

Dr. Murphy's "M5" Kit - 30c Potency ($39.00)

Dr. Murphy's "M5" Kit - 200c Potency ($39.00)

Environmental Remedy Kit - 30c Potency ($450.00)

Isopathic Remedy Kit - 30c Potency ($450.00)

Tautopathic Remedy Kit - 30c Potency ($450.00)

Gemstone Remedy Kit - 30c Potency ($150.00)

Professional Kit I - LM/1 Potency ($575.00)

Other:

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Weebly Email Service. Report Abuse

Forms