Dr Tunde Herbal Medicines

Application Form For Treatment

Please fill in the application form correctly.

All details in this form is required for the shipping of the Herbal Medicine, and also to understand the nature of the infection you have, and for me to offer you a herbal medicine that will be perfect treatment for your condition. For more info, please text me on Whatsapp [ +2348029666702 ]

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

Married

Divorced

Separated

Widowed

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 (HSV)?

Yes

When were you diagnose?

What is the INDEX score on your test result?

Have you noticed any outbreak on your body lately?

Which part of your body are you having the outbreaks?

Your Face

The Genital Part of your body

Both Face & Genitals

None

When did you start seeing the outbreaks?

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