Safe Lab No.		Pathology ID No.		 Collection Date (dd/mm/yyyy)		
				 Collection Time (hh/mm)	am/pm     	
						
 TESTS REQUESTED						

		 UKp - Urinary kryptopyrroles		 HTMA - Hair Tissue Mineral Analysis		 Both UKp & HTMA	
		$80.00 Test Fee + Collection Fee		 $128.00 Test Fee + Collection Fee		 $192 Test Fee + Collection Fee	
		 Collection fee depends on location					
 Collection fees will be paid at the collection point and the test fee will be charged later by the testing lab prior to testing.	

 PRACTITIONER						
Practitioner Type	 Doctor			
 Full Name	 <DrName>	  Country	 Australia	
				
 Practice	 <Practice>	  Email (for Reports)	 <PracEmail>	
				
 Phone	 <DrPhone>	  Fax  (For Reports) 	 <DrFax>	
				
 Address	 <DrStreet>	  Clinic Stamp 		
				
 City	 <DrCity>			
				
 State and Post Code	 <DrState>      <DrPostcode>			

PATIENT INFORMATION						
 Gender	 <PtSex>	  Weight KG	 	
				
 Full Name	 <PtFullName>	  Height	 	
				
 Date of Birth	 <PtDoB>	  Address	 <PtStreet>	
				
 Phone	 <PtPhoneMob>	  City	 <PtCity>	
				
 Email	 <PtEmail>	 State and Post Code	 <PtState>  <PtPostcode>	
				
	       	 Country	 Australia	
PAYMENT INFORMATION						
PAYMENT METHOD		  Collection BPAY No.	

  Credit Card	

	

  Invoice/Bank Transfer	

	Collection fees will be paid at the collection point
and the test fee will be charged later by the testing
lab prior to testing.		
	
 CREDIT CARD:	

	

	

	

	

	

	

	
 CREDIT CARD NUMBER	

/	

     	

	

  EXPIRY                                  CV                                                                                                     PLEASE ALSO COMPLETE PAGE 2	
                                     Send samples to: Unit 7 & 8 / 4 Fremantle Street Burleigh Junction 4220 Gold Coast Queensland Australia

	

COLLECTION CLINIC						
CONTACT NAME	 	  Phone	 <LocationPhone>	
				
 CLINIC NAME	 <LocationName>	  Email	 <LocationEmail>	

UKp CLINICAL NOTES						

Zinc Supplements Paused		  Y		  N		  NA	How many days ago?		    Statin Drug		 Y		 N	

Heart Issues		Y		N	Diabetic		Y		N	ASD		Y		N	Jaundice		Y		N	
																				
Depression		Y		N	Anxiety		Y		N	ADHD		Y		N	Mood Disorder		Y		N	

HTMA CLINICAL NOTES						

Occupation	 <PtOccupation>	  Location of Sample		
 Nape of Neck	
	
 Other	

				
Ethnicity	 <PtEthnicity>	  If So, where	 	
				
 A minimum of one heaped dessert spoon	 Shampoo Brand		
 (or no less than 1 gram) of hair is provided.   
	
   Y	
	
  N	

Hair Treatments	 	 Conditioner Brand	 	

  Bleached	
	
  Permed	
	
  Dyed	

	 Anti-Dandruff Shampoo		
  Y	
	
  N	

				
Colouring agent brand:	 	   Conditioner Brand		
				
Colour	       	   Date of Last Colour		

MEDICATIONS		
	 <SelectedRx>

Supplements		

 Send samples to: Unit 7 & 8 / 4 Fremantle Street Burleigh Junction 4220 Gold Coast Queensland Australia