Test Form

Please print out this page.

Fill in the details below.

Send this page with your payment of $155.00 plus $5.00 per additional item to be tested, and your hair sample to:

The Self Heal Clinic Ltd, 106 Lincoln Rd, Masterton 5810, New Zealand. 

Your Name ..…………………………………………………………………………………………………………………………………………

Postal Address ………………………………………………………………………………………………………………………………………

Phone ……………………………………………………………. Email ………………………………………………………………………….

Age …………………………………………………………………. Gender … ………………………………………………………………….

Please advise whether you have been referred by a practitioner and if so, who?

A brief outline of your symptoms:

Medications/supplements you are currently using:

How to Take the Sample

The approximate size of the hair sample required is a 5 mm thick bunch of hair. It must be cut at the ROOT, close to the skin.

You can use any body hair if the head is shaven. Eg: leg, pubic, chest or underarm. The presence of hair dye is not a problem if it is older than 2 weeks.

Hair samples should be contained in a small sealed plastic bag.

Any additional items to be tested must be appropriately packaged and labelled or they will not be included.

Tests take approximately 4 weeks to process.

When we receive your sample and payment, we will contact you and confirm that we have received it. All tests must be paid for prior to the test being carried out. Your results will be emailed to you with a set of instructions relating to the test result.

Thank you for using our service and we look forward to helping you in your health journey!