Individual Information

Please tell us about yourself. Note that Lie MRI will not sell or rent your information to third parties.

* Indicates a required field
First Name:*
Last Name:*
Email Address:*
Area of interest
for testing:
Telephone:
Company:
Street Address 1:
Street Address 2:
City:
State:
Zip: -
Country:
Gender:
Age:
Handedness:
Do you have
any metal dental
filings?
Do you have
any metal in your
body (outside of
dental fillings)?:
Are you going to
use the findings
in a court case?
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