Lawrence Wilson, MD and Larry McHaney, DC

Lawrence Wilson, MD and Larry McHaney, DC

P.O. Box 54 * Prescott, AZ 86302-0054

RETEST MINERAL ANALYSIS FORM

Please follow the instructions for hair sampling carefully, and cut enough hair to balance the scale. Mark your name, age and the date of sampling on the white hair envelope. To help me design your new program, please answer the questions below. Use the back of this sheet if needed.

The retest fee is $150.00 US dollars. This includes your analysis, a new comprehensive healing regimen and brief follow up phone calls or emails. Payment can be by a check or money order in US dollars, or you may send credit card information, including the expiration date and 3 or 4-digit security code

Mail this sheet, the hair sample and your check, money order or credit card information to: P.O. Box 54, Prescott, AZ 86302-0054.

1. Describe changes you have you noticed in your symptoms or condition over the past several months and describe your main symptoms or complaints at this time.

2. Do you have questions in regard to your diet?

3. Do you have questions in following your supplement program?

4. Do you have questions in regard to sauna therapy or coffee enemas?

5. Do you have questions in regard to lifestyle, emotional aspects or meditation?

6. Are there other concerns you would like us to address when setting up your new healing program?

7. Please indicate your current full address, phone number and email (optional) below. Thank you! You should receive your program within 3 weeks of mailing this form to us with your sample and check, money order or credit card information.

ADDRESS PHONE AND EMAIL

* Nutritional balancing is a means to reduce stress and is not intended as diagnosis, treatment or prescription for any condition or disease. Dr. Wilson and Dr. McHaney offer this service as unlicensed nutrition consultants.