Patient Customer Registration

Thank you for your interest in Ayush Herbs®, Inc.. In order for us to process your order efficiently, please fill out the information in the form below, entering the name of your registered Ayush physician and uploading a doctor's note of authorization. (Note: Your account will not be operational until all appropriate documents and information are submitted and approved by the Ayush Herbs® online operations department) 

If you have any questions or need assistance with this form, please call our office at 425-637-1400 between the hours of 8:00 a.m. and 4:00 p.m. PDT Monday through Friday.

 
Name *
E-mail Address *
Phone Number *
Mailing Address *
City *
Select a State *
Zipcode *
Name of Your Physician *
Upload Completed P.A.S.S. (Patient Access Service System) Form (Up to 5mb - .pdf, .docx, .xlsx, .jpg, .png, .gif) Tip: Use your smartphone to fill out this form so you can take a picture of the P.A.S.S. form and simplify the uploading process *
What is P.A.S.S.?
To learn more about the P.A.S.S. program and to download the form, click here.