Please print this page and fill in the information. Upon completion, send this form along with a saliva sample and a money order for the syncrometer testing and/or consultation to the address below.
You may pay by Visa or money order. Please make all money orders payable to
Health In-Sync.
Please contact us when sending, so we know when to expect your sample.
Please allow 2-3 weeks for results.
Health In-Sync
82 Oakwood Avenue, #3
Toronto, Ontario, M6H 2V8 Canada
Name: ________________________________________________
Address: ________________________________________________
________________________________________________
City: ________________________________________________
State/Prov: ____________________ Zip/Postal Code: _________
Country: ________________________________________________
E-mail: ________________________________________________
Phone #: ________________________________________________
Fax #: ________________________________________________
Organs to be tested (4): ________________, ________________
________________, ________________
Extra organs: _____________________________________________
Health concerns, _________________________________________
pertinent health
information: _________________________________________
_________________________________________
_________________________________________
