Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Biological Sex

Female

Male

Intersex

Other

Rather not disclose

What is the MAIN reason that you would like to purchase herbal extracts from Wild Edge? *

1. Aid in the treatment a specific health challenge

2. Prevention of a specific health concern

3. Optimization of my health

Which treatments you have undertaken for your health challenge or concern, whether you are presently using these treatments or not: *

Herbal medicine under the supervision of a Herbalist

Traditional Chinese medicine herbal treatment

Acupuncture

Osteopathy

Naturopathy

Craniosacral therapy

Yoga therapy

Nutritional advice

Physiotherapy

Allopathic medicine (advice/medication from a Medical Doctor)

Chiropractor

Massage

Homeopathy

Other (please list below)

Please indicate if any of these relate to your current health status. Select NONE if nothing is relevant to you.

currently pregnant

trying to get pregnant

breastfeeding

peri-menopause

post-menopause

NONE

Are you allergic to anything (medications, foods, herbs, environmental and other)? *

YES

NO

I don't know