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

  • Birth Information

  • :
  • 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

  • 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.

  • Use the space below to provide other comments related to this Qi Analysis. This could include more detailed information, delivery instructions, etc.

  • If you would prefer to print and fill out the order form by hand, you can DOWNLOAD THE PDF HERE
  • $0.00
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