Nutrient Companies Preferred-Submittal Form:

       (please send a copy of this form to Nutrabalance with your first lab test file or case study only)

Doctor:                                                                                      Clinic Name:                                                                          

Date submitted:                                Laboratory(s) generally used: _________________________________

Nutrient Companies Preferred: (Choose up to three in a single report)

Anabolic                                                     Biotics                                           NutraCompute             

Zymogen                                                   Douglas                                         Metagenics                     

BioActive Nutritional                                           Nutriwest                                      Standard Process                       

Professional Botanical                            Physiologics                                  Progressive Labs                        

Orthomolecular Products                        PhytoPharmica                            Generic                           

To use the Nutrabalance Reporting Service in your practice, simply follow these four easy steps:

• Obtain Chem. Screen, CBC and UA samples locally; we prefer you use our lab service to do the analysis.
• Fax or email patient blood and urine results, along with the symptomatic questionnaire profile results to our office.  Your first report is always complimentary (see reporting service price sheet for charges after that).
• Be sure to include a Patient Information sheet with every case study, with your ABO type, dietary or supplement choices, so we can better personalize the recommendations.  We will enter the data into our main computer for you, and store the information under your file name.  (If you later purchase access to the data entry feature offered on our web site, we’ll send the patient files to you for follow-up comparison studies).
• Indicate how you want the report sent to you.  The completed patient file can be sent by E-mail, which allows you to print it out on your own letterhead.   Or we will send you two copies by regular mail, one for the patient and one for your records. 

We will charge your credit card $100 to data entry any # of the 750 possible data items using any or all of the first 6 modules the service company allows.  You receive a $10 discount for emailed reports, because we save on printing and mailing costs.

Turnaround time: 1 – 2 in-house working days.

Reliability of data entry:  Guaranteed accurate and thorough or we will repeat at no extra charge.

Verifiable: Lab test correlations are scientifically based, medically documented or research verifiable.

Expense per report: For the cost of individual reports, or prepaid packages, see the Reporting Service Price Sheet.