Biological Immunity Research Institute
13610 N. Scottsdale Rd., #10-456
Scottsdale, AZ 85254 
 International: 480-948-6766
Toll-Free: 888-221-4116 
info@BIRI.org 

 

MemGram® Order Form

Chart or Report
 

Please be sure to submit Client Data and General Symptoms prior to submitting this order.
You will need the Client File # to complete the form below.
 

Click Here To Enter Client Data or to retrieve Client File #.

 

 

Please submit MemGram® Questionnaire
if you have not done so already.

Practitioner First Name:

  

 Practitioner Last Name:

  

Practitioner Login ID:

  

Practitioner Email:

  

Client First Name:

  

Client Last Name:

  

Client File # (This is not Client ID):

   (i.e., 1018544)

If this is a MemGram® retest,
what was the Previous Chart?
(S1-S2-M1-M2):

    

Main symptoms or complaint:

  
MemGram® Chart or Report?   Chart   Report (includes Chart)
If ordering a Report, do you
agree to pay with the appropriate
credit deduction from your account and that this payment is non-refundable?		  
Is this a free MemGram Report order for a previously ordered MemGram Chart?    

Current Chart is ? (S1-M1-S2-M2)
 

  


 

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Emergency: 602-274-2798


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PLEASE NOTE: This website is for general information, research and educational purposes only. Gary A. Martin is a DSc and PhD. He is not a medical doctor. This information has not been evaluated by the FTC nor the FDA and is not meant to cure, treat, prevent disease, nor prescribe or to be used for diagnosis. It is important for you to know that these technologies and dietary protocols have not been evaluated by the FDA in the U.S. or the Health Protection Branch in Canada for safety or effectiveness. No scientific research studies have been done to prove the safety and effectiveness of any protocol discussed on this website. No certification has been granted. We have collected testimonials, but many government regulatory agencies may consider them misleading or deceptive. Please consult with your licensed Health Practitioner before following any of the protocol mentioned on this website, the BIA Software  or our evaluation of your body chemistry. Please be aware that you accept all risk associated with using any of the protocols suggested by the BIA Software or BIRI.
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