Five Flavors Herbal Pharmacy
Prescription Form

Date 

Benjamin Zappin, L.A c., Herbalist
627 Center St., Santa Cruz, CA 95060
Phone: (831) 420-0124
Fax: (831) 420-0101
Email: 5flavors@fiveflavorsherbs.com

Open Monday - Friday, 9am - 5pm


Patient's Name:									#

Referring Physician/Herbalist:							#

Who are we billing? Patient / Practitioner / Existing Account		

Type of Credit Card: Visa / Mastercard / American Express

Crdit Card #

Expiration Date		Code	

Billing Address:




Who are we shipping to? Patient / Practitioner

Shipping Address:





Formula Ingredients/Products and Quantity

Herb name in pin yin / # gram

1.				Quantity	| 1.				Quantity   
                                                |
2.				Quantity	| 2.				Quantity
                                                |
3.				Quantity	| 3.				Quantity
                                                |
4.				Quantity	| 4.				Quantity
                                                |
5.				Quantity	| 5.				Quantity
                                                |
6.				Quantity	| 6.				Quantity
                                                |
7.				Quantity	| 7.				Quantity
                                                |
8.				Quantity	| 8.				Quantity
                                                |
9.				Quantity	| 9.				Quantity
                                                |
10.				Quantity	| 10.				Quantity
                                                |
11.				Quantity	| 11.				Quantity


Powdered Extract / Encapsulation / Bulk Tea / Tincture

Dosage:______________drops / droppers / ml / tsp / capsules

Before/After Meals / With Food_______ x daily / as needed

_______Self Refill

_______Physician/Herbalist Rx only

Special Instructions:

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