KW Botanicals Practitioner Prescription Form

The minimum order for Practitioner Prescriptions is 16 or 32 ounces, varying in accord with the number of herbs in your formula (see table).

If you order an 8 oz. prescription, a $10.00 small size fee applies. We do not fill individualized formulas under 8 oz. You may order an 8 oz. or larger formula & 2 or 4 oz. empty bottles & blank labels, and provide your patients with these smaller sizes.
Larger sizes are priced at a lower cost per ounce.
Please use this form to order your prescription, click the submit button when complete.
We do not process hand written prescriptions or those presented as pdf’s, faxes, or in the text of an email!
Un-modified Refills may ordered with this form. Do Not Re-Submit the Formula for Unmodified Refills – we already have this information! Thank-You!
For ‘standard’ amounts of individual herbs, leave the left column blank. Or: indicate chen, grams, %, or “+” or “–”.
For modifications of TCM formulas, write Pin Yin Name followed by additional herbs desired (refer to our KW Traditional Chinese Medical Formulas Index). If the TCM Formula is not in our Index, provide a reference or type herbs below.
Charges for herbal prescriptions begin at price code 4, and increase in accord with the cost and quantity of herbs used.

Practitioner Prescription

Date

Name of Health Care Provider

Phone/Mobile

____________________________________________________________________________________________________________

Formula 1

Patient’s Name

Select Size of Formula

Select Chen, Grams, %, or + or –	Amount	Latin Name or Pin Yin Name

Click + for each addtional herb

____________________________________________________________________________________________________________

Formula 2

Patient’s Name (initials if same)

Select Size of Formula

Select Chen, Grams, %, or + or –	Amount	Latin Name or Pin Yin Name

Click the + to additional herbs

____________________________________________________________________________________________________________

Please contact me with the price of the formula/s before you fill the prescriptions.

Desired Shipping Service

Ship to my office

Drop ship to my patient

I will pick up at KW

My patient will pick up at KW

Shipping Methods ~ UPS Ground is our default. This arrives overnight within the Bay Area, 2-3 days within California, and takes 5 to 6 days to the east coast.

UPS Ground

3 Day Express

2nd Day Air

Overnight Air

____________________________________________________________________________________________________________

Ship to the most recent address

Patient’s drop ship address or my new address

Address Line 1

City

State

Zip Code

KW BOTANICALS Inc. • 165 TUNSTEAD AVENUE, SAN ANSELMO, CA 94960 • 415-459-4066