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HEALTH FORM FOR HUMANS Please print this out and CLEARLY fill in the relevant boxes.TitleFirst NameSurnameFull AddressEmail AddressDate of BirthTelephone No’sMobileHomeApprox. WeightMale / FemalePlace of Birth including Town and Country Approx. HeightYour Diet over last 6 months =What Symptom’s are you having?Signed ............................................................... Date ..................................... Please Log into Paypal and pay = bodydiagnostics4all@Please State your PAYPAL email Address ……………………& PAYPAL Ref number for your payment…………………..Please CLEARLY State your email address that you want your results emailed too………………………………………………Priority Service ?55 paid for YES / NO Results returned to you via email in 2 working days from receipt of your sample.Standard Service ?45 Paid for YES / NO Results returned to you via email within 2 weeks from receipt of your sample.Remember to enclose a small sample of your hair (Approx. 10 – 20 Hairs about 1 CM OR ? Inch minimum).Place the hair into a small envelope or small plastic sleeve to prevent contamination whilst in the postal system.0355600Bodydiagnostics4allBillinghay Kennels, North Kyme DroveNorth Kyme, Lincoln, Lincolnshire, LN4 4DE00Bodydiagnostics4allBillinghay Kennels, North Kyme DroveNorth Kyme, Lincoln, Lincolnshire, LN4 4DE457200012700Kind RegardsBodydiagnostics4llBryan Stubberfield0Kind RegardsBodydiagnostics4llBryan StubberfieldPlease send the completed form and hair sample to: ................
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