TEST SUBMISSION FORMS
MODERN ALLERGY MANAGEMENT TEST SUBMISSION FORM INSTRUCTIONS:
YOUR INTOLERANCE TEST – PLEASE READ CAREFULLY:
We only require 4-5 strands of hair , if hair is longer than an inch - We test any body hair, the hair root is preferred but not necessary. If cutting the hair, please cut as close to the root as possible - Hair dye/color will not affect testing. Once hair sample collected, place strands into a small sealable bag ensuring the hair remains dry and secure.
Your Test Form will be sent as a download upon completion of your order. If your have any problems with the download and /or printing the form then you may copy the below information onto a piece of paper. Or please contact us and we will mail you the Test submission forms
INCLUDE TEST FORM WITH HAIR SAMPLE
MODERN ALLERGY MANAGEMENT
PLEASE COMPLETE THE FOLLOWING DETAILS (YOU MAY COPY THIS INFORMATION ON A PIECE OF PAPER):
PERSONAL DETAILS: Please enter the details of the person being tested:
Title: ____ First name: ___________________
Last name______________________ M______ F________
Date of Birth: ____________________ Postcode / Zip Code:______
TEST ORDERED:----------------------------Order #------------------------------------------ Please provide an email address to receive test results: EMAIL:_____________________________________________________________________ ABOUT YOUR ORDER
Name of Purchaser: _______________________________
Date of Purchase:______________ _______________________________ IMPORTANT: Make sure you include this form with submission of your test. One form per person testing. Please make sure that all of the above information is completed.
MODERN ALLERGY MANAGEMENT LLC
P. O. Box 13603
Pensacola, Florida 32591 INFO@MODERNALLERGYMANAGEMENT.COM 
850-999-7880