Prescription Form

Herbacy Prescription Submission

Practitioner Information

Practitioner must have an active Professional Account with Si Jin Bao PRO (https://www.professionals.sijinbao.com/)

Type of Prescribing Professional

Name

First

Last

Practice Name

Confirm Email

Practice Address

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Phone

Licensing State

License Number

Patient Information

Please note, you will need 1 form per PATIENT/CLIENT.

Patient Name

First

Last

Patient Email

Confirm Patient Email

TCM Diagnosis / or Conditions

Herbacy Prescription Eastern Physician

Prescriptions are valid for up to 90 days unless otherwise indicated.

Prescribed Formula Prescribed Formula

All Professional internal decoctions are 1oz and last for eleven and a half (11 1/2) days for an adult dosage. Please refer to your SJB PRO account for more information.

Dosage Instructions

If suggesting Off Label Use, please include that in the Special Instructions.

Prescription Expiration Date

Special Instructions / Additional Details / Off Label Use

Please include the requested size (2oz or 4oz) if you have prescribed PRO Revive, Schmoove or Wonderful as well as any special dosage instructions.

Add Formula Remove Formula

Herbacy Prescription Western Physician

Prescriptions are valid for up to 90 days unless otherwise indicated.

Prescribed Formula

All Professional internal decoctions are 1oz and last for eleven and a half (11 1/2) days for an adult dosage. Please refer to your SJB PRO account for more information.

Dosage Instructions

Prescription Expiration Date

Special Instructions / Additional Details / Off Label Use

Please include the requested size (2oz or 4oz) if you have prescribed PRO Revive, Schmoove or Wonderful as well as any special dosage instructions.

Add Formula Remove Formula

Herbacy Prescription Esthetician

Prescriptions are valid for up to 90 days unless otherwise indicated.

Prescribed Formula

All Professional internal decoctions are 1oz and last for eleven and a half (11 1/2) days for an adult dosage. Please refer to your SJB PRO account for more information.

Dosage Instructions

Prescription Expiration Date

Special Instructions / Additional Details / Off Label Use

Please include the requested size (2oz or 4oz) if you have prescribed Revive, Schmoove or Wonderful or any special Dosage instructions.

Add Formula Remove Formula

Terms & Conditions

Please be advised that ancient healing systems such as traditional Chinese Medicine, Classical Chinese Medicine , Ancient Chinese Medicine, Kampo ( Traditional Japanese Herbal Medicine), or Hangul ( Traditional Korean Medicine) are vastly different in the diagnosis and treatment of dysfunctional physiological processes namely diseases. The appropriate trained professional should be consulted on any specified condition. Any alteration to standard dosage recommendations made by the licensed professional will be at their sole discretion and assumes all liability. All licensed professionals hold the manufacturer harmless of all prescribed herbaceuticals offered.

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