Wild Roots Wellness

Apothecary

Wild Roots Wellness – Complimentary Herbal Support Intake Form

In accordance with Health Canada’s latest regulations, all purchases of herbal tinctures, creams, and capsules require a consultation prior to purchase. Our complimentary consultations are available via phone or email for your convenience.

Please complete the form below. We’ll respond within 24–48 hours to support your request. For custom formulas, use the same form and kindly focus on one main health concern so we can give it our full attention.

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Thank you for completing this form.

We’ll be in touch shortly to support your journey. Your information will always be kept private and never shared without your written consent.
1. Reason for Consultation
(Select the option that best describes your request)
2. Do you identify as any of the following?
(Check all that apply)
5. Were these herbs recommended by a healthcare provider?
6. Do you have any underlying health conditions?
7. Are you taking any prescription medications?
8. Do you have any allergies?