Blank Form

Get Personalized Herbal Product Guidance from a Clinical Herbalist

At Dancing Willow Herbs, we are committed to helping you feel empowered to make the most informed decisions about your wellbeing. Fill out the following information in as much detail as possible and one of our herbalists will get back to you in the next 3 business days with customized herbal product recommendations.

Please upgrade to BASE+ plan to unlock this widget for free trial in the app.

First Name *

Last Name *

Phone *

Age

Email *

What are you most wanting herbal support for? *

How long have you been experiencing this? *

What are your specific symptoms? Please be as descriptive as possible. *

How would you prefer to take your herbs? *

If you selected other, please explain:

Are you currently taking any medications? If so, please list below. *

Are you currently taking any other herbs or supplements? If so, please list below. *

Is there anything else you would like us to know?

How did you hear about us? *

Social Media

Friend/family/coworker

Visiting apothecary

Alternative health care practitioner

Other

If you selected other, please provide the source here:

Please acknowledge that we are trained herbalists, not licensed health care practitioners. Any advice given is not intended to diagnose or treat any medical conditions. Our products are not intended to diagnose, treat, cure or prevent any disease. Some herbs may interact adversely with pharmaceutical medications. It is important that you disclose any medications you are taking and that you discuss possible drug-herb interactions with a licensed physician. *

Made by PifyApp.

Order products

Order Total (The sum of all the prices of all the items in the order, taxes and discounts included.)

Contact information

Shipping address

Billing address