Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What other types of practitioners have you worked with before? *

Functional Medicine Practitioner

Naturopathic Doctor

Nutritionist

Osteopath

Chiropractor

Physiotherapist

Massage Therapist

Personal Trainer

Other

What other functional lab tests have you done previously? *

Digestive stool tests

Organic acids

Hormone testing

Heavy metals

Medical specialists

Genetic testing

Lyme/Co-infections

Other

None