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 email a picture of your tongue to with "Phone Consultation Tongue Picture" in the subject line.