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.
  • PAYMENT

  • Price: $250.00
  • $0.00
  • Click on Submit Form button to pay with Credit Card or PayPal

  • If you would prefer to print and fill out the order form by hand, you can DOWNLOAD THE PDF HERE
  • This field is for validation purposes and should be left unchanged.