Java Green Herbal Teas: Custom Tea Request

Welcome to our Custom Tea Apothecary — where your wellness is our inspiration. At Java Green Herbal Teas, we specialize in handcrafting functional, plant-based blends that honor your individual health journey. Whether you’re seeking support for a specific condition or simply want a soothing ritual tailored to your body and lifestyle, we’re here to help.

To begin creating your personalized tea, please complete the intake form below. Your responses will guide us in selecting the most supportive herbs for your needs—mindfully blended just for you.

What happens next?
Once we receive your completed form, we’ll review your information and follow up with any clarifying questions. You’ll then receive a recommended blend (or a few options), along with pricing and suggested use. Most custom orders are blended and ready to ship within 3–5 business days.

If you have any questions along the way or would prefer a brief consultation before placing your request, we’re delighted to assist!

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Personal Information

Name *

First

Last

Date of Birth *

Gender *

Phone Number *

Email Address *

Gender Identity (optional):

• Male
• Female
• Non-binary
• Prefer not to say
• Other

Health Background

Current Health Conditions *

Example: None, diabetes, IBS, etc.

Medications Currently Taking *

Include prescriptions, supplements, or herbal products

Known Allergies *

Example: None, peanuts, chamomile, etc

Body System Support:

Which body system would you like us to support with your custom tea? Select all that apply:

Checkboxes

• Digestive System
• Circulatory System
• Immune System
• Lymphatic System
• Musculoskeletal System:
• Nervous System
• Respiratory System
• Skeletal System
• Urinary System

Additional Comments or Requests: (Optional)

Please share any specific symptoms, flavor preferences, or ingredients you’d like to include or avoid.

Consent and Disclaimer

Please read and sign below:

I understand that the custom tea blend created by Java Green Herbal Teas is intended to support general wellness and is not a substitute for medical advice, diagnosis, or treatment from a licensed healthcare provider. I acknowledge that herbal products may interact with medications or medical conditions, and I agree to consult my physician before using any herbal supplements, especially if I am pregnant, nursing, taking medication, or have a diagnosed medical condition.

By signing below, I consent to the use of the information provided above for the creation of a custom herbal tea blend.

 

Date *

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