Activate Order
Complete this form for every Remedy Testing order to ensure that each report is generated and submitted with accurate information.
Type of test
*
First time
Follow Up
Type of Activation
*
Please Select
Complete Test
Food Elimination Test
Energy Systems Test
Recommended Regimen Test
Kit Only
4-Digit Order Number
*
Confirmation Number
Client Details
First Name
*
Last Name
*
Email Address
*
Cell Phone
*
Please enter a valid phone number, may be used to contact to confirm information.
Date of Birth
*
-
Month
-
Day
Year
Date
Type of Client
*
Human
Animal
Practitioner Details
Help us identify your practitioner on file.
Referring Practitioner
*
Type complete name (ie. Dr. John Appleseed)
Referring Provider Email Address
example@example.com
Back
Next
Acknowledge
Confirm your Remedy Test
Todays Date:
*
/
Month
/
Day
Year
Date
Print Name clearly and provide Signature in box:
*
Clear
Mailing Address
*
Submit
Should be Empty: