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Intake - Epigenetic Hair Follicle Analysis: At-Home Kit for Children Ages 1 to 13
Your Child's Information:
👶🏽🧸
CHILD's
First & Last Name
*
👶🏽🧸
🎂
CHILD's
Date of Birth
(*required by lab to run scan)
*
👶🏽🧸
⚧
CHILD's
Gender at Birth
(*required by lab to run scan)
*
👶🏽🧸⚧ CHILD's Gender at Birth (*required by lab to run scan)
A
Female
B
Male
What is the main concern you would like to address regarding your child's assessment?
*
What are the child's allergies?
*
Does your child have a health condition being treated by a provider? If so, list the condition(s)
*
Parent / Guardian Information
💼 Your First & Last Name - Parent or Guardian
*
📞Phone Number
*
📧
Email Address
*
📦
Shipping Address
*
📍
State of Residence
(
⚠️Note: We do not ship to New York State due to the state's legal restrictions)
*
🌺
Hawaii Surcharge -
If you are located in Hawaii, a $75 shipping surcharge applies. Simply continue to the next question if this does not apply to you
Continue to Terms & Conditions
