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REPEAT ORDER FORM
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REPEAT ORDER FORM
All information is kept confidential.
Please complete the below form prior to order a repeat of any of your prescribed homeopathic's, herbal mixtures or supplements.
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Name
First
Last
Phone
*
Email
Pickup method
*
Pickup from clinic when ready
Express post
Who is your prescribing practitioner
*
Select All
Jim O'Hearn
Indra Share
Josephine Failla
Jacqueline Perri
Please provide what you would like to order.
*
YOU MUST INCLUDE THE FOLLOWING 1) Product name 2) Qty required 3) Herbal mixtures - size and date on last bottle you would like a repeat of
OPTIONAL
Please provide any other notes required to process your order. Including but not limited to pickup date, postal address or extra notes
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Modalities
Naturopathy
Remedial Massage
Chiropractic care
Herbal Medicine
Kinesiology
Homoeopathy
Neuro Emotional Technique (NET)