–Please Create a Template of this Form for Future Use!–

KW Formulation Service E-Mail Form

e-mail Þ

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Name of Health Care Provider: Telephone Date

·  Brian Kie Weissbuch L.Ac. will prescribe an Individualized Formula for your patient based upon the case history you submit on this form. USE THIS FORM FOR INITIAL INTAKES or complex re-evaluations.

·  For REFILLS with case history updates of 2 paragraphs or less, submit as a word document (.doc or .docx) & do not use this template. Do not provide information previously submitted, only changes & new information!

·  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 / 2 page 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.

·  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.

Please send this patient intake form as a Word Attachment (.doc or .docx) in your email. Do not include any
information in the text of the email--this will not become part of the patient’s file! We do not process
hand written case histories or those presented as .pdf, fax, .pages, or in the text of an email!

·  Use the Return Key to create additional lines below. Use the Arrow Keys to move between cells or lines.

·  Replace check boxes with an x. Thank-you for expediting your order with concise and complete information!

Do you need to be contacted with the price of the formula/s before we fill this prescription? Yes No

Patient’s Name______Sex______Age______

Patient’s Chief Complaint/Duration:
Pertinent Health History:
Summary of the main issues you want to address:
Entire Pulse Qualities: / TCM Diagnosis:
Left Pulse / Right Pulse
Distal
Medial / Tongue:
Proximal
Western Diagnosis, as applicable:
Surgeries/Medications/High Dosage Supplements:
Digestion/Elimination, Diet, Appetite, Cravings:
Pain: location, nature, frequency, time:
Vitality/Energy Level & Time, Shen, Color/Facial Diagnosis:
Emotional/Mental Status:
Menses, Pregnancy; Prostate; Libido:
Hot/Cold, Preference/Aversion, Thirst, Sweating:
Sleep:
Respiratory/Lung/Sinus/Nasal/ColdFlu, EENT:
Endocrine, Immune System, Thyroid, Chronic Infectious Diseases:
Skin/Dermatologic:
Urinary:
Additional Information or Lab Test Results
Patient’s Sensitivity: Unresponsive Somewhat dull Very responsive Hypersensitive or reactive

Has your patient had individualized KW Formulas previously? Yes No Most recent date:

If your patient is vegetarian & prefers no animal products in the formula, please check here.

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Desired shipping service (Please see Ordering and Shipping Information for options) Ê: Ship to my office

Patient’s drop ship address, (or address change for my office ) Ê Drop ship to my patient

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For shipments: FedEx 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.

For Expedited Delivery, choose: 3 Day Express, 2nd Day Air, or Overnight Air

Local Folks: I will pick up at KW My patient will pick up at KW

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

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