DIABEZE NATURAL™ – GLOBAL ORDER FORM - Zephania Life Herbal Clinic

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DIABEZE NATURAL™ – GLOBAL ORDER FORM

(For International & Local Clients)
From Zephania Life Herbal Clinic – Tanzania

Safe | Natural | Verified by the Chief Government Chemist (Lab No. 811/2019)

PERSONAL INFORMATION

* Indicates required field

Full Name *

First

Last

[object Object]

Gender *

Date of Birth (DD/MM/YYYY) *

Email *

Phone Number (with country code) *

WhatsApp Number *

SHIPPING DETAILS

Country *

City / Town *

Physical Address (for courier delivery) *

Nearest Landmark *

Preferred Delivery Method *

DHL Express EMS Post Local Delivery (Tanzania only)

ORDER DETAILS

Product Name: Diabeze Natural™ – Herbal Diabetes Treatment

Package *

4-Month Full Dose (6 Bottles – 250g each – Recommended for Full Healing)

Price:
Local Clients (Tanzania): Tsh 650,000
International Clients: USD 471 (Shipping Inclusive)

Expected Delivery Time:
Tanzania: 1–2 Days
East Africa: 3–5 Days
Other Countries: 5–10 Days

PAYMENT METHOD

Choose your preferred payment option *

Western Union – Receiver Name: Khamis Ibrahim Zephania – Country: Tanzania Phone: +255766431675 Mobile Money (Tigo Pesa: +255656620725 / M-Pesa: +255766431675

After payment, kindly send your payment receipt and full details via WhatsApp or Email:
WhatsApp: +255 766 431 675
Email: [email protected]

MEDICAL INFORMATION (CONFIDENTIAL)

Have you been diagnosed with diabetes? *

Type of Diabetes *

Type 1 Type 2 Prediabetes Unknown

Recent Blood Sugar Level (Fasting) *

HbA1c (3-month sugar average) *

Other Conditions (if any) *

High Blood Pressure High Cholesterol Kidney Problems Nerve Pain Overweight

Other health problems you have (please describe as much as possible) *

Are you using hospital medication? *

If Yes, which medication(s)? *

LIFESTYLE DETAILS

Your Current Diet Type *

Normal Diet Vegetarian Low-Carb Diabetic Diet

Do you exercise regularly? *

How many years have you lived with diabetes? *

SPECIAL INSTRUCTIONS / NOTES *

CONSENT & AGREEMENT

Patient Consent and Agreement Declaration *

I confirm that all the above information is true and accurate. I understand that Diabeze Natural™ is a natural supplement and not a hospital drug. I agree to follow the prescribed dosage, diet plan, and lifestyle recommendations provided by Zephania Life Herbal Clinic.

AFTER SUBMITTING YOUR ORDER

You will receive:

Confirmation message via WhatsApp or Email
Tracking number (for shipping)
Free customized diabetic food menu
Continuous follow-up for 90 days

Submit

Zephania Life Herbal Clinic
Mwanza, Tanzania
Natural Healing. Scientific Care. Proven Results.

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