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We appreciate the opportunity to quote your formula. Please complete and submit this form. A customer service representative will respond within 24 hours. All information is strictly confidential and will remain so.

Company name:
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Phone number:	- - ext.
Fax number:	- - ext.
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Product Description:
Product name:
Product description:
Service Requested:	Manufacturing only Manufacturing and Packaging Packaging only
Quote for qty. of:
Expected order date:	/ /
Price point per item:	Min Max
Liquid dietary supplement Cr�me Lotion Gel Powder Other
Viscosity:	(eg. thick paste, syrup, free flowing liquid, etc)
Flavor:
Scent:
Color:
pH:
Sample of the product available?	Yes No
Sample of a similar product?	Yes No
Samples provide Healthy Solutions with a wealth of information. Providing a sample greatly increases the accuracy of our quote and significantly reduces the amount of revisions necessary to produce an acceptable formula. If you do not have a sample please provide a short description of the product. i.e. look, taste, texture etc...
Sample Description:

Package Description: Bottle/Jar:
Packaging:
Size:
Shape:
Color:
Glass or Plastic:	Glass Plastic
Cap type:
Inner seal:	heat induction (foil) pressure sensitive (foam)
Outer seal:	neck band full body sleeve
Customer supplied label:	yes no
Packet/Pouch
Size:
Bulk:
Bulk Container Size:
Scooper:	yes no

Product Packing:
Case Pack:	per case
Additional packaging:	Does your finished product require any additional packaging or kitting? i.e. a retail box.
	Yes No
	If yes, please describe packaging or provide a sample.


Formula:
Serving size:
# of servings per container:

Ingredients:	Qty:	Preferred Source:

Special instructions