Allergy Test Form - allergy and intolerance testing service

HAIR TEST COSTS $110.00

IF YOU WOULD LIKE TO TEST FOR FOOD ALLERGIES AND INTOLERANCES SIMPLY FOLLOW THE INSTRUCTIONS

STEP 1 : Cut a lock of hair (from the roots) of approx 1 inch in length and .5 inch in width. Colour treated hair is fine. Please wrap hair sample up in a small piece of paper or in a zip lock bag clearly marked with your name, address and phone number.

STEP 2: Fill in the Allergy/intolerance testing health form below.

STEP 3: Email this form back to us by clicking the submit button, at the bottom of the page, and send us your hair sample and payment of $110.00, or print this form and send to us with your hair sample and payment of $110.00 (cheques made payable to Elementa). Alternatively payment can be made into bank account Elementa 03 0239 0023001 00 stating your name and reason for payment.
EAV hair testing will be processed once payment has been received.

We will only contact you once we have the results unless otherwise requested.

Send your cheque and hair sample to:

Elementa
347 Remuera Road
Remuera
Auckland
New Zealand

Name
Address
Email
Phone
Date of Birth
Date of sample provided
Which test you want to take?	EAV HAIR TEST
DIGESTIVE ISSUES?	Bloating Belching Pain Diarrhoea Flatulence Constipation
RESPIRATORY ISSUES?	Hay fever Chronic catarrh Sinus congestion Bronchial congestion Asthma Wheezing Hyperventilation
SKIN COMPLAINTS?	Eczema Itching Acne Dermatitis Rashes Hives Dry flakey
GENITOURINARY ISSUES?	Bed-wetting Chronic bladder infection
IMMUNITY PROBLEMS?	Chronic infections Frequent ear infections
MENTAL OR EMOTIONAL ISSUES?	Anxiety Depression Inability to concentrate Insomnia Irritability
MUSCULOSKELETAL COMPLAINTS?	Joint pain Lower back pain
GENERAL WELLBEING	Fatigue Dark circles under eyes Inability to lose weight Headaches Hypoglycaemia Itchy nose or throat Migraines Hyperactivity
OTHER
Do you have any known allergies?
Have you ever been tested for allergies before?
What foods are you currently avoiding?
Are you on any medication?	Yes No
If yes what medication?
How did you hear about us?









Elementa health professional you are working with (if any)
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Allergy & intolerance Test Form

Allery/Intolerance Testing