Healthcare Professionals - TrichAnalytics

Human Hair Analysis Requisition Form

Hair Sampling Instructions

Pluck/pull a minimum of 5 hair strands from scalp.
Ensure the root is intact.
Place hairs in the labelled envelope.
Ensure the labelled envelope has the same sample ID as the requisition form (below).
Send the hair and requisition form to TrichAnalytics Laboratory.

TrichAnalytics Laboratory.
#207, 1753 Sean Heights
Saanichton, British Columbia
V8M 083
Canada
Phone: +1 866 395 5893
Email: admin@trichanalytics.com

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Date Submitted

Report Language*

Name*

First Last

Address

City Country

Phone*

Email*

Results to be sent to (email):*

Same as Healthcare Professional email (I have the patient's consent to directly receive the results).

I am not authorized to directly receive the results of the patient. Please send to another email.

Other email*

Analysis Kit Barcode Number*

Patient Initials (e.g., JC)*

Date of Birth (dd/mm/yyyy)*

Gender at Birth*

Hair Color (Natural)*

Please indicate 'Other' Hair Color

Country of Residence*

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