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Herb Order/Refill
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Email
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Name
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Mobile Phone Number
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Birthdate
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Existing or Previous Patient
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New Patient initial custom herb order will require a in-clinic or telemedicine consult. How would you like to complete our new patient forms
Email me the forms
Download, complete & return forms:
http://mhaom.com/forms/Patient_Registration_Forms.pdf
Complete forms in office
I am a previous patient but haven't had a visit in over 6 months
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Mailing Address (street, city, state, zip code - please verify this is also the billing address of your credit card)
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If your refill requires a phone or in person consult when is the best time to call you?
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Time
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Refill(s) Requested - Please list the date of the formula(s) that were last prescribed to you and the symptoms for each formula.
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Common Clinic Formulas we use that can be requested. If your order is to include these check all that apply.
BSABV-ES: Broad Spectrum Anti Viral/Bacterial 100gm powder $70
BSABV-ES: Broad Spectrum Anti Viral/Bacterial 200 capsules $75
Calm ANX 100gm powder $60
Calm ANX 200 capsules $67
Anchor Spirit 100gm powder $65
Anchor Spirit 200 capsules $71
Clear Canal: Anti-inflammatory 100gm powder $55
Clear Canal: Anti-inflammatory 200 capsules $63
H-DTX (drugs, chemicals, heavy metals, enviro. & airborne toxins) 100gm powder $55
H-DTX 200 capsules $63
L-DTX (Liver damage with elevated liver enzymes) 100 gm powder $75
L-DTX 200 capsules $79
K-DTX (decreased kidney function, damage) 100 gm powder $69
K-DTX 200 capsules $74
Tri-Cholisma (cholesterol and lipid balance) 100gm $58
Tri-Cholisma 200 capsules $65
other
Refill Delivery
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Pick up at our clinic
Ship my order. We will calculate your shipping costs and add to your order total.
How would you like to pay for your order? When your refill is ready to ship we will text you and let you know when to call us for payment - 817-835-0885.
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