DIAGNOSIS ORDER FORM

Order Form

Qi Diagnosis price is $250. For those who wish to order and pay for their Qi Analysis through our online store using a credit card, please fill out and submit the following form.

All information provided will be kept strictly confidential.

Your Information
Name*
First Name Last Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Gender*
Email*
Enter Email Confirm Email
Birth Information
Location Of Birth*
State / Province / Region*
Country*
Date Of Birth*
Month*
Year*
Time*

: HH

MM
Calendar*
Accuracy*
Please Note: The more accurate your time of birth, the more accurate the results. However, even if the time is unavailable an analysis and diet is still possible.
Health Concerns
Please describe any health problems or concerns you are experiencing.

Include any chronic problems, emotional or physical, such as anxiety, fear, depression, anger, impatience, constipation, backaches, headaches, frequent colds, allergies (specify whether digestive, skin, or respiratory), digestive problems, etc.
Additional Information:

Use the space below to provide other comments related to this Qi Analysis. This could include more detailed information, delivery instructions, etc.
This analysis is for:
- Myself
- Another Person
PAYMENT
Qi Balance Constitution Diagnosis
Price: $250.00
Quantity
Payment Method*
- Credit Card
- PayPal
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Phone
This field is for validation purposes and should be left unchanged.

Qi Balance Diagnosis Order Form

Order Form

Your Information

Birth Information

Health Concerns

PAYMENT