TEST SUBMISSION INFORMATION AND FORMS

                   

Thank you for your order

MODERN ALLERGY MANAGEMENT LLC TEST SUBMISSION FORMS & INSTRUCTIONS

ABOUT YOUR INTOLERANCE TEST – PLEASE READ CAREFULLY:

- We only require a few hairs for testing – 5 to 6 strands, if hair is longer than one inch

- We test any body hair. Ideally, we prefer samples to include the hair root, however we understand it can be painful for many people. If cutting the hair, please ensure you cut as close to the root as possible. Once hair sample is collected, please place strands into a small sealable bag ensuring the hair remains dry and secure during transit

- Place hair samples in a secure envelope or postage wallet and post to the following address:

 

Modern Allergy Management LLC 

P.O. Box 11279 

Pensacola, Fl 32524 United States

 

- We strive to return all test results within 10 business days (from the date we receive the package in our office)

All test results will be sent to the email address that you provide on the Test Form.

Complete and enclose the Test Form along with your hair sample.

 

PLEASE COMPLETE THE FOLLOWING

 

Please enter the details of the person being tested: 

First Name: _____________________ Last Name: _____________________

Test Ordered: __________________________   Order # _______________      

 

Please provide an email address to receive test results: 

EMAIL: ________________________________________________________

 

ABOUT YOUR ORDER

Name of Purchaser: _____________________________ 

Date of Purchase: _______________________________

 

IMPORTANT:  Make sure you include this form with submission of your test.  One form per person testing.  Please make sure that all the above information is completed.

 

P.O. Box 11279                         Pensacola, Florida  32524

INFO@MODERNALLERGYMANAGEMENT.COM

850-741-9242

 

ACKNOWLEDGEMENT / WAIVER INDICATING OWNERSHIP

OF HAIR PRESENTED FOR TESTING

This form must be acknowledged and signed prior to your hair

being processed for testing.

Orders that arrive without this signed waiver will not be processed.

I acknowledge that the hair sample that has been sent matches the name

and gender of the individual or animal noted on the order form.

Please print name_________________________________________________________

Please sign name_________________________________________________________