Practitioner Formula Requests

PRACTITIONER FORMULA REQUEST FORM

If you are a practitioner and wish to have a formula filled for one of your patients, we are more than happy to assist you. Please note that formula requests can take between 2-5 days depending on our own clinical patient demands. Please plan accordingly with your patient so that they do not run out of herbs at an untimely instance.

Please note that NO FORMULAS WILL BE FILLED WITHOUT A CREDIT CARD ON FILE. We either need the practitioner’s card on file if they are to pick up or we need your patient’s credit card. If your patient is paying and picking up, please encourage them to call us once you have submitted this to streamline the process. Additionally, there will be a $5.99 Bottling Fee for all formulas under 100 grams.

If you have any questions regarding your formula request, please feel free to call our office at 303-777-7891. We will confirm that we have received your request.

Practitioner Information
Name of Practitioner Prescribing Formula*
First Last
Company/Business Name*
Practitioner's Phone Number*
Practitioner Email Address*
Patient Information
Patient's Name*
First Last
Patient's Phone Number*
Patient's Email Address
Formula Details
Have you sent in a formula for this patient before?*
Do you want to refill a past formula?*
If YES...please complete next question below.
Approximate Date of Last formula filled if applicable.*
Name or Purpose of Formula*
Please put your name for this formula or the purpose for which it is being used in this section. This will go on the label.
Formula*
Please put your formula within this text box. Please include the number of grams on the left followed by the name of the herb. Also include the total number of grams at the end and the number of grams you wish to prescribe per dose and the number of times per day.
Collection/Pick Up of Formula Information
How will this formula be received?*
If picked up at YAO Clinic, by whom?
Does YAO have a Credit Card on File?*
Do we either have practitioner's credit card on file if practitioner is picking up or do we have the patient's credit card on file? If we do not or you are unsure, please phone us at 303-777-7891 to let us know. NO REFILLS WILL BE PROCESSED WITHOUT A CREDIT CARD. All formulas are tailor made for the individual and once it is created, it can not be returned to our inventory. We will not begin this order until a secure credit card has been received/confirmed by our office.
Ship to address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If we are shipping this to the patient, pleas provide the address here. Please note that there will be a minimal shipping charge for this service as well.
Name
This field is for validation purposes and should be left unchanged.

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Practitioner Formula Requests

PRACTITIONER FORMULA REQUEST FORM

Practitioner Information

Patient Information

Formula Details

Collection/Pick Up of Formula Information

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