Re-Test Hair Testing Form

Hair Test Re-Testing Form

Bargara Beach Holistic Health Centre
Compatibility Hair Analysis & Wellness Program

If you have previously completed a Hair Test

Please add the date of your previous Hair test in this form.

This information will be sent to the Hair Testing laboratory and cross-referenced against your previous results.

For breastfeeding mothers:

You can get yourself and baby re-tested while breastfeeding by taking a sample of hair and mixing it with a sample of baby's saliva. Can be posted as well.
Date of previous Hair Test

DayMonthYear
Date
First NameSurname
Phone

Area CodePhone Number
Date of Birth

DayMonthYear
Date
Postal Address

Street Address

Street Address Line 2

Suburb / TownState / Territory

Post CodeCountry
Email
example@example.com
Will you bring in your sample to the clinic? Select 'No' if you want to send your hair sample via post, or 'Yes' if you want to bring it into the clinic.

YesNo
Do you have a child that you are breastfeeding currently who will be participating in the hair testing process?

YesNo
Baby's Name

First NameLast Name
My symptoms include (tick applicable)

AcneDigestiveMigraineADD/HDEarachePMSArthritisExcess mucusPsoriasisBad breathFatugueRashes/itchy skinBloatingFlatulenceRestless legsBrain fogHeadacheSinus/HayfeverConstipationHivesSleep disordersDiarrhoeaIrritable bowelThrushOther
Authorise your order*

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Please note:
Once you have completed payment, we will send you a prepaid envelope and a small, sealable plastic bag, with mailing instructions. If you prefer to bring in your sample to the clinic, select the second option below:
Our 500 standard list items

My Products

Hair Re-Testing Sample collected in-person at the Clinic

$300.00AUD

Hair Re-Testing with Baby Saliva Sample collected in-person at the Clinic

$300.00AUD

Subtotal

$0.00AUD

Tax

$0.00AUD

Total

$0.00AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Hair Test Re-Testing Form

Compatibility Hair Analysis & Wellness Program