Restricted Brands Request Form

About twenty manufacturers that supply specialty and "physician brand" nutritional products require that individuals have access to adequate professional advice before buying. Typically these brands are found in doctors' offices, and are respected by physicians because of the clinical research conducted and the quality, purity, and effectiveness of the ingredients. We created the PATHWAY brand to also meet these standards of quality, purity, and effectiveness.

These manufacturers require screening of customers online to ensure your purchases of these products are handled with extra care, and that you have access to professionals familiar with these products as needed. Thank you for answering these few short questions. Access requests are usually processed within 1 business day.

To continue shopping our other quality brands, click on return to shop to go back.


Contact Information

 
First Name:
Last Name:
Zip/Postal Code:
 
Email Address: username@domain.com
Password:

Please use the same e-mail address and password that you used to register for shopping here. We need this to grant access to the right account.


Question 1
Have you received information from a physician or health care practitioner about these "restricted brands" you would like to be able to purchase online?

Yes No

Question 2
Would you like a nutritional expert to contact you to answer any questions about these brands or products and their use?

Yes No

Question 3
When was the last time you visited your physician?

Less than one year More than one year

Question 4
Is the purchase of this product for personal use by you or for a family member?

Yes No

Question 5
Are you a physician or other medical professional?

Yes No

Question 6
Are you already a Village Green Apothecary customer?

Yes No Not Sure

Question 7

Have you purchased any behind-the-counter "nutritional" products from Village Green Apothecary before?

Yes No Not Sure

Question 8
Please list any doctor's office, store, or web site where you currently purchase these brands.

        

Additional questions and/or comments:


If you have not created an account, you must register first at our Create a New Account page before requesting restricted product access, so there is an account to give access.




Return back to shop for other products.