Revolutionary Healthcare Professional Analysis - TrichAnalytics

About Us
Environmental
Hair Science
Clinical Studies
Nutritional
- Healthcare Professionals
Equine Health
Contact Us
Menu Menu

hcp-banner-small

HAIR ANALYSIS REQUISITION FORM

For online submission, please fill in the form below.

For a printable PDF for manual submission, please click here.

PDF Requisition Form

To request additional hair analysis kits, please fill out the request form.

Request Additional Kits

Hair Analysis Requisition Form

Hair Sampling Instructions

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

TrichAnalytics Inc.
#207, 1753 Sean Heights
Saanichton, British Columbia
V8M 083
Canada
Phone: +1 250 532 1084

Please be sure to write “Exempt Human Specimen” on the mailing envelope.

If you have any questions, please contact:

Julie Christensen
julie.christensen@trichanalytics.com
Phone: +33 6 59 94 61 95

"*" indicates required fields

Healthcare Professional

Date Submitted

MM slash DD slash YYYY

Report Language*

Name*

First Last

Address*

City Country

Email*

Results to be sent to:

Healthcare professional's email

Other email

Please specify other email:

Anonymous Patient Information

Analysis Kit Barcode Number*

Patient Initials (e.g., JC)*

Date of Birth (mm/dd/yyyy)*

MM slash DD slash YYYY

Gender at Birth

Hair Color (Natural)

Please indicate 'Other' Hair Color

Country of Residence

Country

Ethnic Origin (please check all that apply)*

American Indian

East Asian (e.g. Chinese, Japanese, Korean)

Southeast Asian (e.g. Filipino, Vietnamese, Thai, Cambodian)

South Asian (e.g. Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali)

Central Asian (e.g. Uzbek, Kazakh, Tajik)

Black or African American

Hispanic or Latino

First Nations

Métis

Inuit

Middle Eastern

Native Hawaiian or Other Pacific Islander

North or Sub-Saharan African

White / Caucasian

Other race or ethnicity

Other Ethnic Origin

Diet Preferences (please check all that apply)

Dairy

Gluten Free

Keto

Mediterranean

Paleo

Red Meat

Sushi and/or sashimi

Vegetarian

Vegan

Western European

Other

Please List other Diet Preferences

List of Supplements (please check all that apply)

Calcium

Chromium

Cobalt

Copper

Iron

Magnesium

Manganese

Phosphorous

Potassium

Selenium

Sulfur

Vanadium

Zinc

Multi-vitamin

None

Other

Please List Other Supplements

Clinical Diagnosis (Please check all that apply)

Anemia

Cancer

Diabetes

Eczema

Fatigue

Hemochromatosis

Hyperkinesis

Hypercalcemia

Psoriasis

Sceroderma

Osteoporosis

Angina

Arteriosclerosis

Atherosclerosis

Hypertension

Crohn's Disease

Diarrhea

Liver Disease

Kidney Disease

Irritable Bowel Syndrome

Kidney Stones

Peri/Menopause

Anxiety

Attention Deficit

Depression

Learning Disability

Memory Loss

Schizophremia

Manic Depression

Autism

Other

Please Indicate 'Other'

Consent*

I agree to the following three points below:

1. I understand that the interpretation or other information derived from the hair analysis will be based entirely on my professional judgement and knowledge of the patient involved.
2. Hair analysis is not a diagnostic tool; results are for information only.
3. I hereby certify that the above information provided by this office is complete and accurate to the best of my knowledge.

CAPTCHA

Email

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

© Copyright - TrichAnalytics Inc.