Consultant name Consultant's Email Client's name Client's email Parent's name if client is under 18 years old Date of Birth Sex ---MaleFemalePrefer not to say Sample sending date Sample sent as ---Express post Symptoms: Acne / RosaceaADD / ADHDArthritisAsthmaBad BreathBehaviouralBloatingBrain FogChronic FatigueCoeliac DiseaseConstipationDepressionDiarrhoeaEar InfectionsExcess MucousEye InfectionsFlatulenceHeadaches / MigraineHivesIrritable Bowel SyndromeJoint PainM.S.Muscle Aches & PainsNauseaPersistent CoughPMSPsoriasisRashes / Itchy SkinRefluxRestless LegsSinus / HayfeverSleep DisordersTirednessThrush