General Information (Required to Order)

After ordering, please call toll free 877-468-6934 by the next business day or email operations@yourfuturehealth.com.  We cannot ship your order until we know in which state your blood draw will be done.  We must have our MD for that state review your order and results.  However, our MD cannot diagnose, treat, cure, assign insurance codes or act as your personal doctor.
If you live in Alaska, California, Colorado, Hawaii, Kansas, Kentucky, Montana, New Jersey, New York, Rhode Island or South Dakota : Due to the unusually high draw fees charged in these states, we are required to add an additional $25 to your order.
If you live in New Jersey, New York or Rhode Island: Please call us before ordering.

 

Payment Information
Payment VISA MasterCard    

Credit Card Number                

American Express 

  Exp Date - Month Year   

Name As It Appears On Charge Card
Card Address: Street City     State     Zip
Client Information
First Name Preferred Name Last Name

 Address same as credit cardYes No

 
Primary Address
C/O
Street City

State

  Zip
E-Mail Home Phone -- Work/Cell Phone --
  Preferred Contact Home Phone Work/Cell Phone E-Mail Do Not Call
 Do you wish to have your reports by email?Yes No                 Marking "Yes" indicates that your results will ONLY come via email.
Secondary Address
C/O
Street City State   Zip
E-Mail Home Phone -- Work/Cell Phone --
  Preferred Contact Home Phone Work/Cell Phone E-Mail Do Not Call  

Send Kit 

  Send Results 

Send DNA 

Send Mail 

 

Send CC State 

 

 

Height

  ft.  in

Sex Female Male     Weight    lb. Date of Birth 4 digits
How did you learn about YFH?
Whom May We Thank For Your Referral?

Client Comments


Test Selector Shopping Cart and Interpretation  (click on test for details)
Names of TestsPrices for
Yes Test Only Wellness Panel (Includes 10 categories & 56 measures) $304.00

Yes

RBC Elements (Trace, Heavy Metals) $395.00 

Yes

Glutathione $240.00 

Yes

Omega 3 Profile +

AA/EPA Serum Phospholipid Blood Test - Including

GLA, DGLA, ALA, AA/EPA (AA & EPA), Omega 3, DHA (8 scores)

$299.00

Yes Urine Iodine $175.00
Yes Comprehensive Stool Without Parasitology $396.00
Yes Fecal Metals $224.00
Yes Telomere

$499.00

Additional tests will be available in the near future

* CEA does not include PSA or CA 125


To Personalize Your Benefits, Please Answer The Following

Basic Information About Your LifeStyle
How Do You Feel? Fantastic Well OK Poorly Very Poorly
Weight Goal Lose Maintain Gain
Level of Stress Low Average High Very High N/A
Aerobic Sessions/Week 0 1-2 3-5 6+ N/A
Anaerobic Sessions/Week 0 1-2 3-5 6+ N/A
Alcohol: Beer (Each Week) 0 1-2 3-5 6+ N/A
Alcohol: Wine (Each Week) 0 1-2 3-5 6+ N/A
Alcohol: Liquor (Each Week) 0 1-2 3-5 6+ N/A
Caffeine: Chocolate Each Day 0 1-2 3-5 6+ N/A
Caffeine: Soda Each Day 0 1-2 3-5 6+ N/A
Caffeine: Coffee Each Day 0 1-2 3-5 6+ N/A
Caffeine: Tea Each Day 0 1-2 3-5 6+ N/A
Smoking: Packs Each Day 0 1-2 2+ N/A
Number of 8 oz Glasses of Water Each Day 0-3 4-6 7+ N/A
Type of Drinking Water Tap Distilled Spring N/A
Exposure to Chlorine Each Week 0 1-3 4+ N/A
Libido Lacking Healthy N/A
Sleeping Fitfully Soundly N/A
Your Personal Medical History
Skin Disorders Acne Psoriasis Skin Cancer Loss of Pigment
Loss of Hair From None The Head The Body Both Head & Body
Diabetes Migraines Osteoporosis Cancer Heart/Cardiovascular Disease
Arthritis Depression Kidney Disease Liver Disease High Blood Pressure
How frequently do you move your bowels?
More Than Twice a Day Twice a Day Once a Day
3-6 Times a Week Two Times a Week or Less N/A
Women Only
Use BC Pill Hormone Replacement Therapy:     Natural Prescription  
                        Hormone Disorder:  Have PMS Fertility Disorder 
Supplements, Please Check All That Apply
Multi-Vitamin Acidophilus Echinacea Lutein Potassium
Vitamin A Lysine GLA EPA Creatine
Vitamin E Fiber Chromium Calcium Magnesium
Vitamin C Iron Zinc Protein Drink Laxatives
Vitamin B Other

Client Comments


Yes, I understand and agree to The Terms and Conditions including the Doctor Notification Agreement, Cancellation Policy, and Insurance, Medicare, Medicaid Policy No, not at this time.


Terms and Conditions

Below, for your information, is a copy of our Doctor Notification Agreement. This agreement will be mailed to you along with your HealthPrint laboratory kit. For your convenience, a self-addressed, stamped envelope will also be enclosed. Once this signed agreement is returned, we will be allowed to release and mail you your HealthPrint results.

Signing the Doctor Notification Agreement does not require you to have a doctor or to notify your doctor. This is your choice.

DOCTOR NOTIFICATION AGREEMENT

The undersigned agrees that it is his or her responsibility to deliver all laboratory test results, now and in the future, to his or her own physician for any medical interpretation or opinion regarding any laboratory results provided by YFH®.  YFH® does not diagnose, cure or treat any illness or disease.  Available Out of Laboratory Reference Range results will be indicated on the Official Lab Result form provided by YFH® from their Nationally Certified Lab Contract Partners to the undersigned.  The Laboratories’ Medical Directors will review these laboratory test results.  However, this information is not intended to, cannot, and should not be expected to, substitute for a personal consultation with his or her own physician.  Further, the undersigned releases YFH®, their collection sites, their lab partners, their independent representatives, and affiliates from any and all liability for any failure to identify any medical condition or disease.  It is understood and agreed that this is not the purpose of their services. 

The undersigned agrees that he or she will receive a nutritional interpretation (unless it was a Test Only order) of the test results from YFH® that are to be used by the undersigned exclusively, as an educational tool, for personal health purposes.  However, the physician of the undersigned can use these same laboratory results to diagnose and treat disease.  The information (as applicable) on the Your Future Health web site, YFH® brochures, Guide©, Personal Normal Tracker, Health ScoreCardas well as results and information packets are believed to be extremely accurate but such accuracy cannot be guaranteed by YFH®, their independent representatives, and/or affiliates as we are not the originators of the underlying data.  The undersigned also agrees that YFH® neither recommends nor warrants the suggestions of any health professional or person chosen by the undersigned to assist the undersigned with understanding or interpreting the laboratory results and/or the nutritional interpretation, whether the name is provided by YFH® or chosen from an independent source.  It is further agreed that the undersigned waives and releases YFH® from any liability for any injury or loss arising out the use of, or reliance on the recommendations, laboratory results and/or the dietary and lifestyle suggestions provided by YFH® and/or any health professional or person, including any and all claims of negligence and/or product liability.  Before making any changes to the exercise or diet of the undersigned, a health professional or doctor should be consulted.                 

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YFH Order Cancellation Policy

Orders that are canceled within 12 months from the order date will receive an in house credit in the amount of the canceled order (less a $40.00 handling fee) towards the reissue of a new kit and paperwork. The Phlebotomy envelope that contains the requisition (as well as the overnight prepaid mailer bag) must be received by YFH prior to the new test kit being reissued. The credit will be applied towards the tests selected at the time of the reissue at our current pricing. Please note—once you have been to the collection site or if a mobile examiner has come as you requested--there can be no credit, since at that point we are obligated to pay all fees and complete your order.

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Insurance, Medicare, Medicaid Policy

The undersigned agrees that YFH® does not accept or work with any insurance, Medicare, or Medicaid plans because all YFH tests are ordered for prevention and educational purposes. Under no circumstances can YFH be involved with Insurance, Medicare or Medicaid plans with or without your personal doctor's assistance.

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© Your Future Health, 2000,2013                        Last Updated 12/11/2013