Revolutionary Nutritional Requisition Form Analysis - TrichAnalytics

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Nutritional Requisition Form

For online submission, please fill in the form below.

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

PDF Requisition Form

Nutritional 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 barcode 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

If you have any questions, please contact:

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

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Client Contact Details

Date Submitted

MM slash DD slash YYYY

Report Language*

Name*

First Last

Address

City Country

Email*

Anonymous Client Information

Analysis Kit Barcode Number*

Client Initials (e.g., JC)*

Date of Birth (dd/mm/yyyy)*

DD slash MM slash YYYY

Gender at Birth

Hair Color (Natural)

Please indicate 'Other' Hair Color

Ethnic Origin (please check all that apply) - Optional

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) - Optional

Dairy

Gluten Free

Keto

Mediterranean

Paleo

Red Meat

Sushi and/or sashimi

Vegetarian

Vegan

Western European

Other

Please List other Diet Preferences

Please list any dietary supplements that you are currently taking.

Consent*

I agree to the following five points below:

1. I understand that hair analysis is not a diagnostic tool; results are for information only.
2. I hereby certify that the above information provided is complete and accurate to the best of my knowledge.
3. TrichAnalytics Inc. collects and processes my personal data for the purpose of analyzing my hair and providing me with the corresponding results.
4. I am over 18 years of age or the legal representative of a minor.
5. TrichAnalytics Inc. collects and processes my personal data for the purpose of integrating it into an anonymous database intended for scientific research.

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