New Account Setup Form Please enable JavaScript in your browser to complete this form.Practitioner Name *FirstLastClinicAddress Address City and County or StateCountry *Post code / zip code *Email *Number of kits to send:Number of metals to be tested. If you're unsure please list exposure; titanium implants, cobalt chromium hip etc.Please select if you would like us to invoice patients directly: *Invoice clinicInvoice patientWould you like your clinic to be listed on www.melisa.org/melisa-clinics?Yes NoWould you like receive our quarterly newsletter?Yes NoSelect if any of the following areas are of interest:Chronic fatigue, fibromyalgiaAutoimmune conditionsDentistry Titanium dental implants Lyme disease Gluten testing Occupational screeningAllergy to clips, coils, stentsOrthopedic testing Titanium in surgery Spinal implants Scoliosis Other, please specify in comment belowComment MessageSubmit
