Intake Form
Who is ordering the test?
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Party 1
*
First Name
Last Name
Sex:
Date of Birth
*
Party 2
*
First Name
Last Name
Sex
Date of Birth
-
Month
-
Day
Year
Date
Party 3
First Name
Last Name
Sex
Date of Birth
-
Month
-
Day
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Legal Guardian Name (if applicable)
First Name
Last Name
Relationship to Participant (minor)
Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Testing location(s) (provide address for each party)
*
Race/Ethnic Background
*
Alleged Father
*
Are all parties on cordial terms?
*
Has anyone being tested had a blood transfusion in the past 30 days?
*
Yes
No
Do you understand that the total costs of the tests will be billed today?
*
Yes
No
Do you understand that mileage will be billed at $0.67 per mile, paid the day before your test?
*
Yes
No
Do you understand that results are sent to the person who purchases the test?
*
Yes
No
Do you understand there are no refunds and reschedule is subject to add'l fee?
*
Yes
No
Upload Photo ID
*
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*
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