PLEASE FILL OUT THE FORM BELOW

All information provided is kept private with your Flower Essence Practitioner. If you have any questions about the form please get in touch.

Please only provide below details on what you are comfortable sharing. There is no requirement or pressure to share anything that does not feel safe or comfortable to do so.

Name

First Name

Last Name

Date of birth

YYYY

Shipping address

How did you hear about Heka Healng / This offering

Terms and Conditions

Before partaking in this offering Please confirm you have read and agree to our disclosure terms and conditions

Yes I have read and agree

Please share a brief outline of your Mental health history and current experience

Please share a brief outline of your physical health history and current experience

Please share a brief outline of your spiritual health history and current experience

Please share a brief outline of your emotional health history and current experience

Please share what you would like to achieve out of this experience

If you think there may be anything else releavnt to your experience that you would like to share please do so

Would you like your remedy made with

(can be changed in future)

regular organic brandy preserve

non alcoholic colloidal silver preserve

Have you heard about or used Flower remedies before. If so please provide details of your experience with them.

yes/no

PLEASE FILL OUT THE FORM BELOW

ACKNOWLEDGEMENT