DNA HAIR ANALYSIS – APPLICATION
Personal Details (Strictly Confidential)
Name: M/F (please circle) Tel:
Postcode: Mobile: Landline:
Email: Age: Height:
First Test Retest (please tick)
How did you find us?
Medication (prescription only)
Do you smoke?
Please list the top three symptoms which you are currently suffering from, in order of seriousness. You can write a full medical history on the reverse of this form if you wish.
Place a minimum of three hairs - anywhere on the body will do - in the space below making sure that the root of the hair is attached. PLEASE DO NOT TAPE OVER THE ROOT.
Medical History – please enclose extra pages if this space is not enough
CREDIT CARD PAYMENT DETAILS
VISA SWITCH OTHER
CARD NO: / / /
START DATE: / EXPIRY DATE: / SECURITY CODE:
(Last 3 digits on white strip on back of card above signature)
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