Dr Tunde Herbal Medicines

Application Form For Treatment

Please fill in the application form correctly.

All information requested in this form is required to register, process and ship your herbal medicine order, as well as to help us better understand your condition. Once we receive the information, your order for the herbal medicine will be registered, processed and shipped to the address you provided.

Application Form

First Name:

Last Name:

Your Age:

Your Gender:

Female

Male

Others

Your Email Address:

Phone Number: (plus country code)

WhatsApp Phone Number:

Your Country:

Your State & City (San Jose, CA):

Your Zipcode / Post Code

Your Current Home Address:

Occupation / Profession:

Your Marital Status:

Single

Dating

Married

Have you been Diagnose?

Yes

Are you Pregnant?

Yes

Taking any medications, currently?

Yes

FOR HERPES (HSV 1-2) PATIENTS ALONE:

Have you been Diagnose of Herpes?

Yes

When were you diagnose?

Have you noticed any outbreak on your body?

When did you start seeing the outbreaks?

Which part of your body are you having the outbreaks?

Facial part of my body

Genital part of my body

Both Facial & Genital part

None

Have you tried any herbal medicine? Or contacted any herbal doctor before me?

How did you hear about us?

We understand the importance of your privacy, and we assure you that all information provided will be handled with the utmost confidentiality and in compliance with all relevant data protection regulations.

If you have any questions, concerns, or need assistance with this process, please do not hesitate to ask me. For more info text me on Whatsapp: [ +2348029666702 ]

Dr Tunde Herbal Medicine