Mikei Product Request 

Mikei Product Request 

Thank you for your interest in MIKEI® Red Reishi products.

* indicates required question

    PRACTITIONER INFORMATION

    Full Name*

    Professional Title/Designation*

    Clinic or Practice Name

    Clinic Full Address*

    Phone Number*

    Email Address*

    Website or Social Handle (if available)

    Years in Practice*

    CLINIC & PATIENT FOCUS

    Primary Modalities Practiced*

    Common conditions you treat (check all that apply)

    PRODUCT INTEREST & INTENDED USE

    Have you used or prescribed red reishi or medicinal mushrooms before?*

    Primary reason for requesting a sample (check all that apply)*

    FUTURE PARTNERSHIP OPPORTUNITIES

    Can we follow up with you for any of the following?*

    Preferred follow-up method*