On The Go Genetics, LLC Client Intake Form

On The Go Genetics, LLC Client Intake Form

Welcome to OTG, LLC! Our intake form is designed to gather essential information for your DNA testing process. Please provide accurate details to ensure seamless and accurate results. Your privacy and confidentiality are our top priorities. Thank you for choosing On The Go Genetics, LLC for your genetic testing needs!
Who is Ordering the test?*

First NameMiddle NameLast NameSuffix
Phone Number
Please enter a valid phone number.
Email where results will be delivered
example@example.com
Who is being tested? (Party 1) CHILD FIRST AND LAST NAME

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Sex
Race
Who is being the tested? (Party 2) (any additional parent/aunt/sibling/grandparent)

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Sex
Race
Who is being the tested? (Party 3) (any additional parent/aunt/sibling/grandparent)

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Sex
Race
Address of Testing Party 1: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address of Testing Party 2: (only complete if we need to travel to this address to test)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a lingering domestic issues where parties cannot be in the same room?*
Have you had a blood transfusion in the last 30 days?*
Have you had a bone marrow or stem cell transplant?*
Disclaimer:

Please note that the information provided in this form will be used solely for the purpose of DNA testing services by On The Go Genetics, LLC.

The deposit today is 100% non-refundable unless the DNA test is canceled by OTG, LLC or canceled by an official party within 48 hours of the date of the test. Remaining payment is due the day of the test. A link will be sent. If the payment goes unreceived, a collector will NOT be dispatched out.
Any mileage fees associated with the test is due prior to a collector being dispatched out.
All mileage fees are subject to 0.67 cents per mile and is calculated for each stop from our headquarters address: 2245 Wisteria Dr., SW, Snellville, GA 30078.
Results are sent via email (postal mail by request only) within 5 business days of the test being taken.
We are committed to safeguarding your privacy and will not share your personal information without your consent, except as required by law.

By completing and submitting this form, you acknowledge and agree to these terms.
Do you understand that no additional guests are allowed during the collection?*
Photo Identification of Party Ordering Test:*

Cancelof
You understand that we will bill you for any balances and mileage prior to coming out: *
How Did You Hear About Us?
By signing this application, you authorize On The Go Genetics, LLC to charge your provided payment method for any and all DNA testing services, including but not limited to service balances and mileage fees, on the day of service. You acknowledge that any outstanding balances or additional charges related to the service will also be charged to the card on file. A non -refundable deposit of $50 will be required to secure appointment. Invoice will be sent to the email provided.
Signature*

Clear
By proceeding, you agree to these terms and conditions and authorize the transaction as outlined.
Should be Empty: