Herbal Consultation
Evaluation Input Form

Instructions...

• Fill in the User and Contact Information.
• For each Concern - Check Areas of Concern that Apply and Select your Level of Concern.
• Answer all the Questions that are relevant in the other Areas.
• Please let me know about any Specific Issues in the Comment Areas.
• When you are done Click the "Submit Form" button to send the Information to Divas Botanicals.
• You may also Print this form and mail it if you wish.
• The Fee for this Consultation is $50.   Please send a Check or Money Order for this amount to Divas Botanicals.
• Once your payment is received the Recommendations will normally be returned to you within a week.
• Be sure and check how you would like the Recommendations sent near the bottom of this Form.
• Payments should be sent to:
  
  Divas Healing Herbs & Gifts
  6100 John Lane
  Pueblo, Co 81004
  719-568-5581
  
• all Information is Strictly Confidential.
  Recommendations for Herbs or Other Alternatives are Strictly Voluntary.
  Recommendations are not meant to Replace your Physician's Advice.

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  Marital Status  SingleDivorcedMarried   Age 

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Copyright 1998-2006 Divas Botanicals
Revised: 02/23/2008