IMMUNE, ZEN & VITALITY Tonic Form Name * First Name Last Name Email * Are you taking any other medications? No Yes - please book a Tonic Consult before placing your order What is your age? * 18-24 25-36 37-56 57-60 Are you currently pregnant or trying to conceive? * No Yes - please book a Tonic Consult before placing your order Do you have high blood pressure or low potassium? * No Yes - please book a Tonic Consult before placing your order Do you take regular blood thinners or aspirin? * No Yes - please book a Tonic Consult before placing your order Are you currently taking antidepressants? * No Yes - please book a Tonic Consult before placing your order Do you have a history of liver disease? * No Yes - please book a Tonic Consult before placing your order Have you had any major surgeries in the last 6 months? * No Yes - please book a Tonic Consult before placing your order How much alcohol do you consume per week? * 0-3 standard drinks 4-6 standard drinks 7-11 standard drinks 12+ - please book a Tonic Consult before placing your order Do you have any known allergies to herbal medicine? * No Yes - please book a Tonic Consult before placing your order Are you currently taking warfarin? * No Yes - please book a Tonic Consult before placing your order Extra information Thank you for filling out this form.If you answered ‘YES’ to any of these questions, you will need to book a Tonic Consult before consuming one of our Tonics, please book here. If you have any further questions, please contact us here.
