Herbacy Prescription Submission 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 * Eastern Physician (LAc OMD DOM AP) Western Physician (M.D. D.O. D.C. ARNP PA) Esthetician Name * Name First First Last Last Practice Name * Email * Confirm Email * Practice Address * Practice Address Street Address Street Address Address Line 2 Address Line 2 City City State / Province State / Province ZIP / Postal Code ZIP / Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Phone Licensing State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific License Number * Patient Information Please note, you will need 1 form per PATIENT/CLIENT. Patient Name * Patient Name First First Last 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 * PROPRIETARY FORMULAS 止嗽捕蒸汽湯 A.I.R.™ - Zhi Sou Bu Zheng Qi Tang – 肺 Feì Breathe Easy Not Wheezy (Stop Cough Immune Support Decoction) 板藍根湯 Ban Lan Gen Tang 大肠湯Da Chang Tang (Clear Your Skin & Empty the Bin™) 大止痛湯Da Zhi Tong Tang (Extra-Strength Stop Pain Decoction™) 復蘇 盔甲 汤 Fu Su Kui Jia Tang (Restore the Armor Decoction™) 湯San Jiao Qi Ji Tang – 三焦 San Jiao (Three Burning Spaces) 酸棗仁湯 稀薟草 Suan Zao Ren Tang with Xi Xian Cao 續斷湯Xu Duan Tang (Broken Bone Decoction™) 枳實理中湯Zhi Shi Li Zhong Tang – 小腸 Xiao Chang (Regulate the Middle Decoction) 止痛湯Zhi Tong Tang (Stop Pain Decoction™) 清心凈心湯 Qīng Xīn Jìng Xīn Tāng (Clear the Mind and Purify the Heart) CLASSICAL FORMULAS 安眠湯An Mian Tang 八昧地黃湯Ba Wei Di Huang Tang 八珍湯Ba Zhen Tang- (Eight Treasure Decoction) Tonify Qi And Blood 八正湯Ba Zheng Tang-Eight Rectifying Herbs (Eliminate Dampness /Restore Function to Lower Jiao) 保和湯Bao He Tang- 胃 Weì Preserve Harmony Decoction 保济湯Bao Ji Tang 補中益氣湯Bu Zhong Yi Qi Tang- (Tonify the Middle and Augment the Qi Decoction) 柴胡疏肝湯Chai Hu Shu Gan Tang 柴胡加龍骨牡蠣湯Chai Hu Long Gu Mu Li Tang 川穹荼調湯Chuan Xiong Cha Tiao Tang 大補陰湯Da Bu Yuan Jian Tang 大承氣湯Da Cheng Qi Tang 大止痛湯Da Zhi Tong Tang 湯Dan Qiang Tang 定喘湯Ding Chuan Tang 獨活寄生湯Du Huo Ji Sheng Tang 獨活寄生湯Du Huo Shen Qi Tang 湯Du Ji Xiao Du Tang 二陳湯Er Chen Tang 二妙散Er Miao San 防風通聖湯Fang Feng Tong Sheng Tang 防己黃芪湯Fang Ji Huang Ji Tang (Stephania & Astragalus Root) 葛根湯Ge Gan Tang 湯Gua Lou Xie Bai Bai Jiu Tang 歸脾湯Gui Pi Tang- 心 Xīn 桂枝湯Gui Zhi Tang 黃連解毒湯Huang Lian Jie Du Tang 藿香正氣湯Huo Xiang Zheng Qi Tang (Agastache Decoction to Rectify the Qi) 湯Jian Pi Tang (Strengthen Spleen Decoction) 金匱腎氣湯Jin Gui Shen Qi Tang (Tonify Kidney Qi Formula) 理中湯Li Zhong Tang (Warm the Middle and Cold Tang) 六昧地黃湯Liu Wei Di Huang Tang (Six-Ingredient Decoction with Rehmannia) 龍膽瀉肝湯Long Dan Xie Gan Tang (Gentiana Decoction to Drain the Liver) 湯Ming Mu Di Huang TangPai Qi Yin Tan (Discharge Gas Formula) 平胃湯Ping Wei San (Calm the Stomach Decoction) 美活勝濕湯Qiang Huo Shen Qi Tang (Notopterygium Decoction to Overcome Dampness) 清氣化痠湯Qing Qi Hua Tan Tang (Clear the Qi and Transform Phlegm Decoction) 入參敗毒湯Ren Shen Bai Du San Tang (Ginseng Decoction to Overcome Pathogenic Influences) 湯Shao Yao Tang 湯Shen Ling Bai Zhu Tang ( Ginseng, Poria, and Atractylodes Macrocephala Decoction) 生隊湯Sheng Mai Tang (Generate the Pulse Decoction) 十全大補湯Shi Quan Da Bu Xin Tang ( All-Inclusive Great Tonifying Decoction) 十灰湯Si Huang Tang (Ten Partially-Charred Substances) 四金湯Si Jin Tang (Stone) 四君子湯Si Jun Zi Tang- (Tonify Qi Formula) 四逆湯Si Ni Tang (Frigid Extremities Decoction) 四物湯Si Wu Tang (Four-Substance Decoction) 酸棄仁湯Suan Zao Ren Tang (Sour Jujube Decoction) 蘇子降氣湯Su Zi Jiang Qi Tang (Perilla Fruit Decoction for Directing Qi Downward) 桃花湯Tao Hua Tang 天麻鉤藤飲Tian Ma Gou Teng Tang ( Gastrodia and Uncaria Decoction) 天王袖心丹湯Tian Wang Bu Xin Dan (Calm Insomnia Heart And Kidney) 溫膽湯Wen Dan Tang (Warm the Gallbladder Decoction) 葦茎糖Wen Jing Tang (Reed Decoction) 五苓湯Wu Ling Tang (Five Ingredient Decoction with Poria) 吳茱英湯Wu Zhu Yu Tang ( Evodia Decoction) 香砂六君子湯Xiang Sha Liu Jun Zi Tang ( Six Gentlemen Decoction with Aucklandia and Amomum) 小柴胡湯Xiao Chai Hu Tang- 肝 Gān ( Minor Bupleurum Decoction) 小承氣湯Xiao Cheng Qi Tang ( Minor Order the Qi Decoction) 小 湯Xiao Ke Tang 逍遁湯Xiao Yao Tang (Rambling Decoction) 血府逐瘀湯Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction) 銀翹湯Yin Qiao Tang ( Honeysuckle and Forsythia Decoction) 右歸湯You Gui Tang- 腎 Shèn Restore the Right (Kidney) Decoction 左歸湯Zuo Gui Tang- 腎 Shèn Restore the Left (Kidney) Decoction TOPICAL FORMULAS Revive Gel™ Revive Cream™ Schmoove Gel™ Schmoove Cream™ Wonderful Gel™ Wonderful Cream™ Trauma Paste™ Other 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 * 2x Daily 3x Daily 4x Daily 5x Daily 6x Daily 7x Daily 8x Daily 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 * PROPRIETARY FORMULAS 止嗽捕蒸汽湯 A.I.R.™ - Zhi Sou Bu Zheng Qi Tang – 肺 Feì Breathe Easy Not Wheezy (Stop Cough Immune Support Decoction) 復蘇 盔甲 汤 Fu Su Kui Jia Tang (Restore the Armor Decoction™) 大止痛湯Da Zhi Tong Tang (Extra-Strength Stop Pain Decoction™) CLASSICAL FORMULAS 保和湯Bao He Tang- 胃 Weì Preserve Harmony Decoction 清氣化痠湯Qing Qi Hua Tan Tang (Clear the Qi and Transform Phlegm Decoction) 銀翹湯Yin Qiao Tang ( Honeysuckle and Forsythia Decoction) TOPICAL FORMULAS Revive Gel™ Revive Cream™ Schmoove Gel™ Schmoove Cream™ Wonderful Gel™ Wonderful Cream™ 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 * 2x Daily 3x Daily 4x Daily 5x Daily 6x Daily 7x Daily 8x Daily 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 * TOPICAL FORMULAS Revive Gel™ Revive Cream™ Schmoove Gel™ Schmoove Cream™ Wonderful Gel™ Wonderful Cream™ Yucca'b'Cool™ Yucca'b'Energized™ A Wonderful Mask™ 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 * 2x Daily 3x Daily 4x Daily 5x Daily 6x Daily 7x Daily 8x Daily 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. Today's Date * Signature * Clear Captcha If you are human, leave this field blank. Submit