KW Formulation Service ~ Intake Form

Please use this form to provide an initial Patient History, click the submit button when completed.
Individualized Formulas are provided in 16 or 32 oz. sizes. 8 oz. sizes incur a $20.00 surcharge.
Complex conformations with severe disharmonies or multiple diagnoses may require 2 formulas.
Please provide a concise and complete case history. Abbreviate freely! Review of an initial intake case history plus a 1 to 2 page lab report is provided for a fee of $25. to $45., depending upon the complexity of the patient’s conformation.
Review of additional reports or longer case histories incur higher fees. Review of 2 paragraphs or less for refill information updates are provided for a $10. fee. Longer re-evaluations incur higher fees.
Submit patient history update here.
We will call or email if we require clarification or additional information.
We will provide you a copy of your patients’ formulas with instructions for administration.
We do not process hand written case histories or those presented as .pdf, fax, .pages, or in the text of an email!

Brian Kie Weissbuch L.Ac. will prescribe an Individualized Formula for your patient based upon the case history you submit on this form.