Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Preferred Contact Method
Email
Phone
How did you hear of us?
Social Media (e.g., Instagram, Facebook)
Search Engine (e.g., Google, Bing)
Referral (Friend, family, or colleague)
Health & Wellness Blog or Website
In-Person Event or Workshop
Other (please specify)
Health & Wellness Goals? (Select all that apply)
Are there specific times of day you plan to use this blend?
Are you interested in a:
Do you have any flavor preferences?
(Select all that apply)
Are there any flavors or herbs you dislike or want to avoid?
*
Preferred Strength?
Do you have any allergies or sensitivities to herbs, plants, or foods?
*
(List all)
Do you follow any dietary restrictions
(Select all that apply)
Are you currently taking any medications or supplements?
*
Do you consume
(Select all that apply)
Is there anything else you'd like us to know about your preferences, health goals, or lifestyle?
Would you like to join our mailing list for wellness tips, new product announcements, and exclusive offers?
Yes
No
Thank you for completing our Personalized Blend Questionnaire!
We appreciate you sharing your preferences with us. Our team is excited to get started crafting your blend, and we’ll soon share a couple of options for you to choose from.
In the meantime, feel free to explore our blog and resources on herbal wellness. We’re honored to be part of your journey toward a healthier, more balanced life!
Warm regards,
