Hair Tissue Mineral Analysis Request


Please send hair sample accompanied with payment to:
Wisdom for Health Clinic
137 Coode street Como Perth
Western Australia 6152

- Name
- Address
- State & Postcode
- Telephone
- Email address
- Age
- Sex
- Pregnant
- Height
- Weight
- Occupation
- Current Medications
- Your Symptoms
- Your Symptoms
- Your Symptoms
- Date Of Sample
- Location Of Sample
- Your Hair Color
- Hair Preparation Used
- Shampoo
Patient Details (Please write clearly)
SURNAME FIRST NAME
ADDRESS
STATE POSTCODE
TELEPHONE
EMAIL
EMAIL
AGE
SEX
PREGNANT
HEIGHT
WEIGHT
OCCUPTION
CURRENT MEDICATIONS
Reason for Test – Your Symptoms
1. 
2. 
3. 
NB: Reference ranges on reports are based on age, gender and scalp hair.
Hair Sample Details
Samples best not be obtained from hair that is permed, coloured or chemically treated. Untreated hair provides the most reliable result.
DATE OF SAMPLE DAY MONTH YEAR
LOCATION OF SAMPLE i.e.
Scalp/Pubic/Axillary/Other
Note: Hair treatments and preparations may artificially elevate the result of some elements reported.
Your NATURAL HAIR COLOUR
HAIR PREPARATION USED
SHAMPOO