Online Registration for Our Current Pilot Surveys

Thanks for requesting more information to determine your eligibility for participation in one of our current Nutritional Pilot Surveys. Please choose the most appropriate condition listed below to begin the process.

If your condition is not listed, please choose the "Other" selection and let us know what it is. If you generally have good health but still want to participate, please select "Improve my Health".

Completion of the Intial and 6 monthly Evaluation Forms is necessary to receive Matched Funding. Completing these forms will be vital for the ongoing reasearch that we are undertaking.

Applicant Information

Fill in the information below to determine eligibility in our current Pilot Surveys.

First Name *

Last Name *

Contact Phone *

Email Address *

Contact Preference *

Please select all conditions that apply *

Shipping Destination *

USA

Canada

Mexico

Other Other

I have read and understand the "What is the Matching Funds" information. Click Here to Review. *

Yes

No

I understand that by completing this Online Registration Form, I will be eligible to participate in any Pilot Survey lasting for a period of six months and will receive 2 for 1 product when ordering. *

Yes

No

I understand that all Participants are required to complete Forms 1 through 7 to qualify for the 2 for 1 special pricing. I also understand that if my Forms are not returned, I do not qualify for the Pilot Survey 2 for 1 special price. In which case, I agree to pay the regular price for all product received. *

Yes

No

Acid reflux	ADHD	Asperger
ALS	Alzheimer's	Brain function
Cancer	Cardiovascular	Dementia
Depression	Diabetes	Heart attack
Huntington's	Leukemia	Lyme's
Mitochondria function	Multiple sclerosis	Poor metabolism
Parkinson's	pH level evaluation	Stress
Stroke	Improve my Health	Other Other