Refill Form Contact Information First Name* Last Name* Email * Birth Date Cell Phone Number * Zip Code* Summary of Health Symptoms improved since last visit?* Yes No I am not sure Some are improving and some aren't First time at clinic Have you experienced changes in your health since last refill?* Yes No Please explain any health changes (leave blank if none) Changes in medication since last refill?* Yes No If medications changed, provide daily medications Please list which herbal formulas you would like refilled (tea, tincture, topical, vitamin, or supplement?)* Have you made any changes to your daily habits or wellness practices as a result of what you learned at Wild Roots* Yes Not yet, but I plan to No Prefer not to say Since receiving care at Wild Roots, have you experienced any of the following? (Check all that apply) * Less physical pain or discomfort Improved Sleep Reduced stress or anxiety Improved digestion Better energy levels Stronger connection to my body None of the above Prefer not to say Since coming to Wild Roots, has your access to herbal care improved* Yes, significantly Yes, somewhat No change It's harder now Prefer not to say Before Wild Roots, how easy was is it for you to access herbal or alternative care?* Very difficult Somewhat difficult Neutral Somewhat easy Very easy Prefer not to say Anything else your herbalist should know?
