Sensitivity Test Submission Form
Title:
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Please Select
Miss.
Mrs.
Ms.
Mr.
Sex:
*
Please Select
Female
Male
Name
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First Name
Last Name
Email
*
example@example.com
Confirm Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Your Dietary / Allergy History (Intolerances)
Lactose Intolerant
Gluten Intolerant
Wheat Intolerant
Peanuts
Seafood Intolerant
Other
Your Dietary / Allergy History (Allergens)
Hayfever
Trees
Pollen
Mold
Grass
Dust
Dogs
Cats
Rabbits
Guinea Pigs
Sulfa (drugs)
Latex
Metals
Fragrances
Bleach
Penicilin
Other
**DISCLAIMER AGREEMENT**
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This documentation certifies that the corresponding patient has read and agrees to the below disclaimer regarding the context surrounding this line of testing: 1. If you have any health or medical concerns you must consult with a registered medical practitioner in respect of those. 2. Our testing services are not intended to be a substitute for professional medical advice, diagnosis or treatment. 3. The purpose of our testing services is to provide you with a convenient, quick and confidential means of being tested for whether you are more likely to have a given sensitivity. However, our test results are indicative and are not intended as medical advice of any kind, and should not be or considered as a diagnosis or used as a basis on which to take medication, without first consulting a registered medical practitioner. 4. It is essential that anyone considering changing their diet must consult a registered medical practitioner in the first instance. 5. All possible diagnoses generated by our tests must be discussed and confirmed with a registered medical practitioner. 6. If you think you may have a medical emergency, call your doctor or the emergency services immediately. 7. 100% accuracy of all test results cannot be guaranteed. However, our laboratory partners work to high industry standards and procedures at all times. 8. Our staff will not provide medical advice given that they are generally not medically qualified. Any advice given by our staff should therefore not be construed as medical advice or any diagnosis. 9. Hair testing (bioresonance therapy) is categorised as a form of Complementary and Alternative Medicine (CAMs). CAMs cover a wide range of therapies that fall outside of mainstream and conventional medicine. Conventional medicine does not currently recognise bioresonance therapy as it has not been subject to significant and extensive scientific research and testing. As with all of our testing services, Bioresonance testing does not constitute a medical diagnosis and is not intended to be a substitute for professional medical advice, diagnosis or treatment.
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I understand that I need to post my hair sample and that a physical kit will not be sent to me.
I confirm I have read and agree to your terms and conditions
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