| Your Details |
| Your Name: * |
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| Your Address 1: * |
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| Your Address 2: * |
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| Your Town/City: * |
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| Your County/State: * |
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| Your Postcode: * |
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| Your e-mail: * |
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| Your Daytime Phone: * |
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| Your Other Phone: * |
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| Your Date of Birth (dd/mm/yy): * |
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| Your Gender: * |
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List all current medical conditions: * |
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| Are you taking any conventional medications? (Y/N): * |
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| If yes, please list each medications: * |
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| Are you taking any artifical hormones? (Y/N): * |
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| Are you pregnant? (Y/N): * |
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| If so, when is your due date? (dd/mm/yy): * |
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| Are you breastfeeding? (Y/N): * |
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| Please list any allergies or sensativities: * |
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| Do you have any non-natural item in your body, eg stent, breast implants, metal pin? (Y/N): * |
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| Please list the products you wish to order: * |
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| Are you ordering products recommended to you by a healthcare professional, eg homeopath, naturopath, herbalist, GP? (Y/N): * |
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| If so, please give the name and telephone number of your healthcare professional (we will not contact them without your permission): * |
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| May we contact your healthcare professional for details of their recommendation for you? (Y/N): * |
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DISCLAIMER
Any form of self-treatment or alternative health involves an individual's acceptance of some risk, and no one should assume otherwise. The information and advice on the Holistic2go.com website or provided by our team should not be taken as a substitute for medical advice or treatment, especially if you know you have a specific health complaint, or have symptoms that have not yet been investigated and diagnosed.
Our advice is that you find a GP who is sympathetic to the usefulness of natural medicine, and ensure that you have a thorough and accurate diagnosis of all symptoms, before you make your informed choice of appropriate treatment options.
Please note that it is your responsibility to inform us of changes in your medical condition. In particular, if the conventional drugs you take change, or if you are diagnosed with a new health condition, you must let us know by email before your next order is placed.
IMPORTANT NEXT STEPS
• Please now re-save this form, then send it as an attachment, by email, to info@holistic2go.com
• We will then contact you by phone or by email to discuss your needs, and give you your unique customer registration number, enabling you to purchase suitable items marked (R) on the holistic2go.com website.
• Emails do occasionally go astray, so please call us if you have not heard back within 2 working days. Please note that we cannot be held responsible for breaches of confidentiality due to the use of email.
• If you have any difficulty with your registration, please call 01273 7155822 (UK) or +44 1273 715822 (non-UK) and we will be pleased to help.
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