Please Enter Your Information Below:
(* is required to enter)

* First Name         * Last Name Sex

* Address

* City   State (Sample: N.Y)  * Zip

*Email   Occupation

* Credit         Credit Type * Exp.Date /

Birthday / / * Telphone(Office)         Telphone(Home)

Please Mark check When It is Appicable:
Asthma	Heart Conditon	BloodPressure /	Diabetes	Bad Breath
Hot fresh	Alcoholic	Inhale Drugs	Pregnant	Have a Pacemaker
mens early	mens late	Weigth lbs	Swollen	Emotionaly anger
Insomia	Bowel Times aday	Depresesive	Fatique	Sweat at daytime
Feet cold	Soft bowel	H.I.V.Positive	Headache	Sweat at night
Thirsty	hard bowel	Black Pain	cough	Urine times/night
Red Eyes	Shoulder Pain	Ingest Tobacco	Dizzy	Buring Urine
Acne	Poor Appetites	2_much Appetites	Hepitis	Pain in rib
Skin Iche	Skin Break Out	losing hair	Stiff Neck	height ft in.

Cost of the phone consultation $30.00. The charge will be made when the consultation proceeds. We use natural herbs and/or food supplements that should restore the harmony of the body. We do not intend to use such herbal formula to substitute the regular medical procedures. In fact,for any emergency, we highly advise you to consult your doctor. If any answers are private matters,please leave it blank. All your information are used for consultaion purpose only.

In case of litigation, we can not provide your lawyer with information of our care.

Please use the space below to describe your health issues:

Addtionally, to facilitate the consultation process, please send a picture of your tongue to [email protected].

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