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Reporting
Service – Submittal Form
Doctor: ______________________________
Patient Name:_______________________________
Date Submitted:___________ Date Drawn: __________ Laboratory:_________________________________
Nutrient
Companies Preferred:(Choose up to three)
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____Abunda
Life
____BioActive Nutritional Detox
____Douglas
____Metagenics
____Nutriwest Core
____Professional Botanicals
____Standard Process
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____Biotics
____DNA
____Generic
____Nutriwest
____Physiologics
____Progressive Labs
____Orthomolecular Products |
For fastest
response have the lab or your office Fax results to Nutrabalance,
Fax # (303) 494-7887 or Phone (800) 468-7903.
Reporting
Service Prices
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Report
Credit #
|
Item |
Price |
Terms |
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1
|
Nutrabalance
Program (charge includes all additional data entry: Trace
& Toxic Metals, Amino Acids, Food Allergies, Fatty Acids
& Symptomatic Profile as well as one consultation per report.)
|
$75.00
(does not include any lab fees.) |
Pre-payment
with order. (Check, MC, Visa, Discover, Am.Exp.) |
|
6
credits
|
Nutrabalance
Programs |
$400.00
($66.67/ rpt) |
Pre-payment
with order. (Check, MC, Visa, Discover, Am.Exp.) |
|
12
credits
|
Nutrabalance
Programs |
$700.00
($58.33/ rpt) |
Pre-payment
with order. (Check, MC, Visa, Discover, Am.Exp.) |
|
20
credits
|
Nutrabalance
Programs |
$1100.00
($55.00/ rpt) |
Pre-payment
with order. (Check, MC, Visa, Discover, Am.Exp.) |
|
30
credits
|
Nutrabalance
Programs |
$1500.00
($50.00/ rpt) |
Pre-payment
with order. (Check, MC, Visa, Discover, Am.Exp.) |
Total Amount
Paid $_________
____Check Enclosed
____Charge my M/C, Visa, AmEx, Discover
Credit Card
# __________________________________________ Exp. Date ________
Signature ________________________________________________
Send or fax
this completed and signed form to:
Nutrabalance
c/o Total Health Enterprises
4740 Table Mesa Drive, Suite B
Boulder, CO 80305
Phone: 800-468-7903
Fax: 720-304-6527
info@nutrabalance.com
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