Herbal Assistance Program Application
Download Manual Application
Information on Program
Applicant Name:
Date of Birth:
Shipping Address:
Billing Address:
Auto-Shipment:
Yes
No
Telephone:
Email
How do you prefer to order?
Online
Phone
E-mail
How do you prefer to Ship?
USPS
Fed-Ex
UPS
Medical and/or health conditions:
Current Medications/Herbal Supplements:
Are You A Veteran?
Yes
No
Are You Disabled?
Yes
No
Are You On Social Security?
Yes
No
Do You Meet The 25% Poverty Guidelines?
Yes
No
Medical Provider:
Holistic Healer:
Other Healing Services:
Additional information:
Submit
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