Hair Analysis Order Form- Full Version

Hair Analysis Mail Kit (Full)

All information is used for kit registration
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Mailing Address (UPS delivered) *(We can not ship hair kits to New York state) *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail (tracking and report)*
example@example.com
Phone Number*
Are you Vegan/Vegetarian?*

YesNo
Are you pregnant or nursing?*

YesNo
How did you hear about this?*
Additional Comments

My Products

Hair Analysis KitEpigenetic Hair Analysis. Just 4 hair follicles are needed to test all nutrients (minerals, vitamins, fatty acids, aminos, antioxidants). Environmental toxins (metals, radiation, chemicals). Resistance indicators (parasite, mold, fungus, bacteria, virus). EMF levels, Trigger foods, Trigger additives. The kit is delivered UPS with a return label. You receive a 45 min explanation of your 30-page report and are given a 90-day protocol via Zoom.

$299.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Details
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Credit Card Number	Security Code
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Hair Analysis Mail Kit (Full)