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Australian Institute for Functional Medicine
24 years of community service

 

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Membership Registration

Membership with the Institute is free for life.

Membership carries with it, entitlement to:

 Low Cost Health Assessments

 Free Newsletter

 Post-Free Therapeutic and Preventive supplements worldwide

Please identify and describe yourself, and fill in your unique ID number by giving your first name initial and surname initial followed by the last six digits of your phone number. Queries marked with an * are for epidemiological research and your personal medical history file if needed.

eg. John Smith JS123456

 

First Name
Last Name
Date of Birth
*Sex Male Female
*Height
*Weight
ID Number

Choose one of the following options:

* Your Blood Type if known
O
A
B
AB

          *Choose one of the following options:



Copyright 2004.Australian Institute for Functional Medicine. All rights reserved.
Revised: 02/27/05