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Order form personalised supplement plan

HGUK Test
EFORE YOU BOOK THE TESTS, PLEASE READ THE FOLLOWING CAREFULLY :
IMPORTANT INFORMATION
1. Having the tests carried out does not constitute a guarantee that your hair will re-grow.
2. The test results do not constitute a medical diagnosis. For a medical diagnosis, please
consult your doctor or dermatologist.
3. Please do not order tests 4 or 5 if you are pregnant or breastfeeding. If you fall
pregnant while on the treatment plan, you will need to inform me immediately.

4. The treatment plan you will receive when you order the tests is tailor-made to your
specific needs and is not transferable to someone else.
5. You will need to start the treatment plan within four weeks of receiving the test results.
After four weeks, the test results are no longer valid.

6. Be aware that you may be required to cut out certain foods as part of the treatment
7. If the tests show metal toxicity or invasive organisms, it can take up to 18 months to
detox from these. During this time, re-tests will have to be carried out approximately every

three months. A re-test is currently £80.
8. It may be necessary to have amalgam fillings removed if they are a problem.
9. This is not a quick fix treatment plan. If your hair growth can be restored, it can take up
to 12 months to see progress with your hair.

10. Being vegan may severely restrict your chances of regrowing your hair.
11. HGUK testing is different from conventional laboratory testing.
Conventional laboratory testing
Advantage: You will get a figure of how much of a toxin has been detected in your urine, blood or
hair sample.
Disadvantage: The figure you get as a result of conventional testing will not include the amount of
toxins that have been stored in body tissue over the years. Stored amounts of toxins can be
considerable so that the actual amount of toxins present in your body is higher than the figure you are given by the laboratory. Disadvantage: You will be given a 'normal range value' with your test results. The normal range will
tell you whether the level of toxin in your body is considered 'acceptable' or whether it is considered a
danger to your health. However, the normal range does not take into account differences between individuals. What is normal for one person is abnormal for the next person.
Disadvantage: If you are within the normal range, your doctor will do nothing about the toxin
because the test gave you the 'all clear'. However, if you are sensitive to a particular toxin, this toxin
can cause you health and hair loss problems, even if you are within the normal range. Your 'all clear' is therefore inaccurate.
HGUK testing
Disadvantage: You will not get a figure for the toxins that were found in your sample. Instead, you
will be told that there is or that there is not a problem with a toxin.
Advantage: The HGUK testing will pick up a toxin in its entirety, i.e. in your blood, your urine and in
your body tissues where it may have settled over the years. This means you will not get a false 'all clear' message from the test.
Advantage: You get a tailor-made plan of exactly which supplement/s you need to take to remove
the toxin from your body. In that way, physical balance is restored which increases the likelihood for
your hair to recover.
Advantage: You get a tailor-made plan of how long you need to take your supplements for and at
which dosage.
Advantage: You can ask questions via e-mail if you are not clear about your treatment plan or feel
you have a problem with any of the supplements, and I will get back to you with an answer, normally within 2 working days, often faster.
PLEASE RETAIN THIS SHEET FOR YOUR RECORDS.
________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80 HGUK Test
ORDER FORM
Please carry out the following test/s (please tick boxes you require):
1 Toxic metals
2 Invasive organisms £ 80
3 Food intolerances £ 80
4 Big supplement test £ 100 *
5 Big test (Tests 1 – 4) normally £340, but reduced to £180, provided your
sample and payment reaches us by 14th March 2014.
PLEASE WRITE CLEARLY
. Country ……………………………………………………… Your personal details will NOT be sold to third parties.
□ I would like to pay by cheque, made out to Vera Peiffer.
(Cheques can only be accepted in British Pounds.)
□ I would like to pay with PayPal.
Please send me a PayPal invoice to my e-mail address so that my credit card
details stay safe. (You do not need a PayPal account yourself to use this facility.) □ I would like to pay £ ……. by credit card.
* Tests 4 and 5 require answers to the questionnaire which follows this form.
Tests 4 and 5 will only be carried out if the completed questionnaire is enclosed.
6 wks

________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80 HGUK Test
How to take a hair sample
If your hair is actively falling out at the moment: Go with your fingers through your hair and send me hair that has been left in your fingers. I need at least 10 hairs.
If your hair is thinning but not actively falling out: Cut off approximately ten hairs of at
least 2 centimetres length from the back of your neck, close to the scalp. If your hair is
shorter, please send a nail sample instead.
It does not matter if your hair is dyed. It would be better if your hair has not been washed before you cut it.
DO NOT TAKE HAIR FROM A BRUSH AS THIS COULD CONTAIN SOMEONE ELSE’S HAIR Put your sample into a white clean piece of paper and sellotape it shut. I cannot
accept hair that has been wrapped in plastic.
How to take a nail sample
If you have no hair or your hair is too short, send in some nail clippings from finger nails. If you wear nail varnish, you need to take it off before you cut the nail. The larger you can make the clipping, the better. If in doubt, send little clippings from several nails. Put your sample into a white, clean piece of paper and sellotape it shut. ________________________________________________
QUESTIONNAIRE
WHERE DID YOU HEAR ABOUT HAIRGROWTH UK? Please tick relevant box.
ڤ Recommendation ڤ Scoot ڤ HIBU (Yell.com) ڤ Regrowing Hair Naturally book ڤ Help Your Hair ebook ڤ Amanda Brooks ڤ Sue Hambleton HAIR AND SCALP
Please explain briefly what type of hair loss you are suffering from, for example whether your hair comes out in round patches, whether it is overall thinning or only thinning in certain areas.
Do you also suffer from dandruff, skin irritations, itchiness or sensitivities or any other conditions on the scalp? If so, please describe briefly here.
Do you suffer from any other health problems except hair loss? ______________________________________________________________________ Do you have any silver/grey amalgam fillings in your teeth? How many? Have you ever had any silver/grey amalgam fillings in your teeth that were Do you have any gold fillings or gold crowns in your teeth? ________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80 HGUK Test
Do you have any root canal fillings in your teeth? Do you have problems with your gums, for example bleeding or puffiness?If you do, which one? ________________________________________________________________
FOOD AND DRINK
How much alcohol do you consume in a week? What foods do you eat between meals as snacks? What type of liquids do you take during the day? Do you eat chocolate and/or sweets every day? Do you find it hard to resist sweet foods (biscuits, cakes, sugary drinks)? Do you chew gum? If so, which brand and flavour? _________________________________________________________________ Do you have any pets or do you come in daily contact with animals? Do you smoke? If yes, how many cigarettes on average? Have you ever had operations with general anaesthetics? If yes, how If you are currently on prescribed medication, please state what you
are taking:
DO NOT DISCONTINUE PRESCRIBED MEDICATION UNLESS ADVISED TO DO SO BY
YOUR DOCTOR.
________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80 HGUK Test
Are you having any conventional treatment for hair loss such as How many cordless phones do you have in your home? In which rooms are the cordless phones located? For approximately how many minutes/hours a day do you use your mobile Do you have any tattoos? If so, how many? Do you have any body piercings except ear lobes? If so, where are the piercings? Do you have any metals in your body (dental implants, screws in bones, shrapnel etc.)? Please specify.
Do you suffer from any of the following more than you feel you should? Please tick the relevant box:ڤ unexplained weight loss ڤ constipation ڤ unexplained pains in the body ڤ diarrhoea ____________________________________________________________________________________________ Emotional issues
Are there any current life situations that are causing you stress in your private or professional life? Please describe briefly.
Are there any past life events that you feel had a negative influence on ________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80 HGUK Test
_________________________________________________________________ Supplements
Are you currently taking any supplements?
If so, which brand and what dosage?
(Please include supplements for bodybuilding if you take those.)
_________________________________________________________________ Profession
________________________________________________________________________ For female clients:
38.
______________________________________________ I confirm that I have read the Important
Information on page 1 and have retained the sheet
for my records.

……………………… …………………………………
Date

Signature
order form with completed questionnaire
payment and
hair/nail sample
Vera Peiffer
75 South Lane
Ash GU12 6NL

Great Britain
________________________________________________________________________ Hairgrowth UK 75 South Lane Ash Surrey GU12 6NL GREAT BRITAIN 80

Source: http://www.hairgrowthuk.net/Downloads/FORM%20hair%20analysis.pdf

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