Cheek Swab/Rife Update Request Form

Please complete the following and return to the clinic with your cheek swab. Thank you!

Date of Cheek Swab Collection*

Month/Day/Year

Reason for Distance AK Request*

Check all that apply
**Fee for retesting is based on time spent: $225

General follow-up for Conners Clinic recommended supplements and diet

Symptom-specific testing (list below)

New Rife program/frequencies (fee includes time spent programming)

Test supplements recommended by another practitioner/self (list below)

Please list specific signs/symptoms, new/changed test results, or supplements you would like tested or included in requested Rife update - please briefly explain.*

I understand that Dr. Conners is NOT licensed to practice medicine in my state, DOES NOT practice medicine; DOES NOT prescribe, give, or administer any drug or medicine; DOES NOT offer or undertake to prevent, diagnose, correct, or treat any disease, illness, pain, wound, fracture, infirmity, deformity or defect; DOES NOT offer to undertake or perform any form of surgery or hypnosis; and that cheek swab testing is done to provide new/additional/modified recommendations and/or Rife programming. I agree to this testing on these terms and SUBMITTAL of this cheek swab and/or a Testing Request Form constitutes my full agreement.

Signature in Agreement*