Initial General Information

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Curated by Eileen Durfee, founder of Wellness Shopping Online · Updated August 2026

If you are unable to submit the form electronically, you can print it out: Page 1 Page 2 Page 3 Page 4 Page 5

Fill in your information, scan, and email back to us at Contact@WellnessShoppingOnline.com. We do not accept mailed printed copies of the forms.


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These statements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease. Hair tissue mineral analysis is a screening tool for nutritional and toxic-element status. Always work with a qualified healthcare professional on choices that suit you.

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