Hair and Saliva Scan Intake & Order Form

Patient Gender*

Patient Name*

First NameLast Name

Patient Birth Date*

Birth Date

Patient Height (in inches)*

Patient Weight (in lbs)*

Patient E-Mail*

example@example.com

Reason for seeking genetic information:*

ex: Nutrition recommendations, lifestyle recommendations, Exercise recommendations, supplement recommendations

Please list if you have any drug allergies

ex: Penicilin

Have you ever had (Please check all that apply)

Please list if you have other illnesses:

Please list any operations and dates of each:

Please list your current medications and supplements:

Exercise (days per week)

Never1-2 days3-4 days5+ days

Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan80% strict diet, 20% loose diet

Alcohol Consumption

I don't drink0-2 glasses/day3-4 glasses/day5+ glasses/day

Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day

Include other comments regarding your Medical History

My Products

Full System ScanThe Full Scan is RHC's broadest and most all-inclusive analyses available. The Bioresonance scanning we do provides a wide range of insights, including levels of high bioenergetic stress within your system performance, nutritional and hormonal imbalances, general categories of resonating toxins, food and environmental sensitivities, and a balancing regimen.

$348.90 Choose an option:

Remedy ScanNatural remedies such as herbs and homeopathics as well as nutritional supplements, can provide the necessary components to help our bodies reach optimal health. Instead of guessing which remedies or supplements are going to be best for an individual, at RHC, clients and patients are analyzed then scanned against several remedies.We are able to bioenergetically test hair and saliva to identify what remedies balance your current body-state best. Although a particular remedy may balance well for one person, a completely different remedy may balance best for another person, even if the two people are experiencing similar issues. The benefit of the Remedy Scan is to keep costs down in between Full Scans and continue on a balancing regimen that addresses your current layer of health.

$91.50 Choose an option:

Awareness ScanThrough the same way RHC's analyses can determine physical stressors and imbalances throughout the body, we can also determine resonating emotional imbalances and factors revolving them. The Awareness Scan bioenergetically tests for emotions, colors, gems, essential oils, key nutrients, and polychrests, providing a customized infused remedy to purchase to address these imbalances.

$124.50 Choose an option:

Prenatal ScanThe prenatal scan provides expecting mothers with information on their bioenergetic health, including approximately 350 resonating food and environmental sensitivities as well as any energetic imbalances in key vitamins, minerals, amino acids, enzymes, and fatty acids.

$174.00 Choose an option:

Balancing ScanThe Balancing Scan includes a bioenergetic hormonal and nutritional imbalance scan, general category of resonating toxins, and a balancing regimen that may include herbs, homeopathy, and nutritionals.

$152.00 Choose an option:

Sensitivity ScanThe Sensitivities Scan is designed to help hone in on specific energetic environmental and food sensitivities. RHC scans your bioenergetic levels in your hair and saliva samples against nearly 350 potential environmental and food sensitivities.

$152.00 Choose an option:

Dietary ScanThe Dietary Scan provides those health conscience individuals information on their bioenergetic health, including approximately 350 resonating food and environmental sensitivities as well as any energetic imbalances in key vitamins, minerals, amino acids, enzymes, and fatty acids.

$174.00 Choose an option:

Add a Virtual Results Consultation Product Image

Add a Virtual Results ConsultationMeet with Dr. Jen Lourey, D.C. for 30 minutes virtually to discuss the results of your scan and receive personalized recommendations based on your goals and preferences.

$60.00

Product Name

$ Free

Total

$0.00

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Hair and Saliva Scan Intake & Order Form

General Information

Medical History

Healthy & Unhealthy Habits