|
|
___________________________________________ |
|
DOB:
|
___________________________________________ |
|
Address:
|
___________________________________________ |
|
City,
State, Zip Code:
|
___________________________________________ |
|
Phone
(home, work):
|
___________________________________________ |
| Can
we leave a message regarding appointment information? |
Yes__
|
No__
|
|
| Race: |
Caucasian__
|
Black__
|
Hispanic__
|
Asian__
|
Native
American__
|
Other__
|
|
|
Child's
Name:
|
___________________________________________ |
|
DOB:
|
___________________________________________ |
|
Address:
|
___________________________________________ |
|
City,
State, Zip Code:
|
___________________________________________ |
|
Phone
(home, work):
|
___________________________________________ |
| Can
we leave a message regarding appointment information? |
Yes__
|
No__
|
|
|
Alleged
Father's Name:
|
___________________________________________ |
|
DOB:
|
___________________________________________ |
|
Address:
|
___________________________________________ |
|
City,
State, Zip Code:
|
___________________________________________ |
|
Phone
(home, work):
|
___________________________________________ |
| Can
we leave a message regarding appointment information? |
Yes__
|
No__
|
|
| Race: |
Caucasian__
|
Black__
|
Hispanic__
|
Asian__
|
Native
American__
|
Other__
|
|
|
*Additional
Tested Person:
|
___________________________________________ |
Relationship:
|
___________________________________________ |
|
DOB:
|
___________________________________________ |
|
Address:
|
___________________________________________ |
|
City,
State, Zip Code:
|
___________________________________________ |
|
Phone
(home, work):
|
___________________________________________ |
| Can
we leave a message regarding appointment information? |
Yes__
|
No__
|
|
| Race: |
Caucasian__
|
Black__
|
Hispanic__
|
Asian__
|
Native
American__
|
Other__
|
|
| *note
- extra fee(s) will apply for additional tested person(s). Please
call 1-800-551-7763 for details |
|
Preferred
appointment day/time:
|
__________________________ |
Specimen
type:
|
Blood___
|
Buccal___
|
Contact Person: _____________________________ |
Phone (include area code): _______________________ |
Is there
a representative or attorney involved?
For
mother and/or child:
For alleged father:
|
|
|
Name
of representative:
Name of representative
|
_________________________________
_________________________________
|
|
| |
|
Payment
|
Full payment or a deposit of $100
is required to initiate the DNA testing process. We accept
MasterCard, Visa, Discover,
American Express and payment by Money Order.
Please do not mail cash. The $100 deposit is non-
refundable after the process has been initiated. The collection
facility in your area will charge a fee ranging from
approximately $15 to $45 per person to collect specimens. Once
we have received this form along with your
payment, our scheduling department will begin to coordinate an
appointment in your area. You will receive a call
from our scheduling department with your DNA test appointment
information.
|
(
) Standard
6-10 Working Day Service - $420
|
(
) FAST PROFILE
5 Working Day Service - $500
|
(
) ULTRA FAST PROFILE
3 Working Day Service - $700
|
|
|
Full
Payment $ ____________________
|
Deposit
$ ____________________
|
|
|
(
) Master Card
|
(
) Visa
|
(
) Discover
|
(
) American Express
|
Card
No: ___________________________________
Expiration Date: _______________
|
|
Exact
Name on Card: _____________________________ Cardholder's
Signature: _____________________________
|
| |
| |
|
Mail to: Genetic Profiles, 10675 Treena
St., Suite 103, San Diego, CA 92131
|
