Client Intake Form

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INSTRUCTIONS FOR SENDING SAMPLES

  1. Please call or email before sending in a sample. We must put you into the schedule and we can only do so many analysis' per week.

  2. Place two (2) swabs saturated with your saliva (before brushing) into a Ziploc bag.

  3. Place a few (preferably unpainted) nail clippings (fingernails, toenails or combo) in a separate Ziploc bag.

  4. Pull a few strands of hair (directly from scalp to get new growth.) Place in a Ziploc bag. Skip this step if you don't have any hair.

  5. Write your name on the outside of EACH Ziploc bag with a marker.

  6. Mail samples with this form via whatever carrier you choose. Please DO NOT REQUIRE a signature on our end for receipt. You may send in a plain or padded envelope. When you make your appointment we will tell you which address to send your package to.

Health History

PLEASE READ THE FOLLOWING AND SIGN BELOW

THE A/O, QEST AND ASYRA SYSTEMS PROVIDE A COMPLETELY NON-INVASIVE METHOD FOR GAINING VALUABLE INFORMATION ABOUT YOUR BODY’S VITAL FUNCTIONS. THE PRIMARY OBJECTIVE OF THE PROCEDURE IS TO DISCLOSE PATTERNS OF STRESS AND TO PROVIDE FEEDBACK TO HELP IN RECOMMENDING A PROGRAM TO RESTORE EACH SYSTEM AND MERIDIAN TO BALANCE. I UNDERSTAND THAT THE HAIR, NAIL, SALIVA ANALYSIS DOES NOT PROVIDE A MEDICAL DIAGNOSIS, AND THAT MY TECHNICIAN MAY RECOMMEND FURTHER MEDICAL TESTING. IF I SUSPECT THAT I NEED FURTHER MEDICAL INTERVENTION, I UNDERSTAND IT IS MY RESPONSIBILITY TO CONSULT WITH MY PHYSICIAN. I GIVE MY PERMISSION FOR THE SCREENING TECHNICIAN TO EVALUATE ME ON THE A/O, QEST OR ASYRA SYSTEM. I UNDERSTAND THAT BY DOING SO MY TECHNICIAN IS NOT BECOMING MY PRIMARY CARE PROVIDER OR PHYSICIAN. I UNDERSTAND THAT THE SCREENING TECHNICIAN WILL GIVE ME INFORMATION ABOUT MYSELF BASED ON THE A/O, QEST, OR ASYRA EVALUATION AND THAT THE TECHNICIAN WILL MAKE RECOMMENDATIONS TO IMPROVE MY HEALTH BASED ON WHAT IS FOUND DURING ANALYSIS. ANY DECISION TO FOLLOW THROUGH WITH THE PROGRAM WILL BE MY OWN DECISION. FURTHERMORE I UNDERSTAND IT’S THE RESPONSIBILITY OF MY PRIMARY CARE PHYSICIAN TO MAKE ANY ADJUSTMENTS ON PRESCRIPTION MEDICATIONS. I UNDERSTAND THAT ANY ITEM PURCHASED AT BE HEALTHY NATURALLY LLC IS NON-REUNDABLE. ANY DECISION TO FOLLOW THROUGH WITH THE PROGRAM WILL BE MY OWN DECISION, AND I WILL NOT HOLD THE SCREENING TECHNICIAN, OR AMPLIFY NATURALLY, RESPONSBILE.

I UNDERSTAND THAT ANY PRODUCTS PURCHASED ARE NON-REFUNDABLE.

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