Gray Positive Solutions LLC – DNA Intake Form

Gray Positive Solutions LLC – DNA Client Intake Form
Welcome to Gray Positive Solutions LLC!

Our intake form is designed to gather the essential information needed for your DNA testing process. Please provide complete and accurate details to ensure smooth scheduling and accurate results.

Your privacy and confidentiality are our highest priorities. All information you provide will be handled securely and in compliance with HIPAA and applicable privacy laws.

Thank you for choosing Gray Positive Solutions LLC for your DNA testing needs. We look forward to serving you.
Ordering Party Information
Who is ordering the test?

First NameLast Name
Phone (Person Ordering Test)
Please enter a valid phone number.Format: (000) 000-0000.
Email (Where Results Will Be Delivered)

Confirmation Emailexample@example.com
Address (Ordering Party / Testing Party 1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Test Participants
Party 1 (Child):
Name

First NameLast Name
Sex
DOB:

MonthDayYear
Date
Race
Party 2 (Parent/Relative):
Name

First NameLast Name
Relationship:
Sex:
DOB:

MonthDayYear
Date
Race:
Party 3 (Optional):
Name

First NameLast Name
Relationship:
Sex:
DOB:

MonthDayYear
Date
Race:
Medical / Collection Questions
Is there a lingering domestic issue where parties cannot be in the same room?
⚠️We will schedule separate appointments to ensure comfort and privacy for all parties.
Have you had a blood transfusion in the last 30 days?
⚠️ DNA testing may be affected by a recent transfusion. Please contact our office before scheduling.
Have you had a bone marrow or stem cell transplant?
⚠️Due to transplant procedures, DNA results may not be conclusive. Please contact our office for guidance before proceeding.
Upload Photo Identification of Person Ordering Test

Upload Government-Issued Photo ID
Cancelof
Additional Contact Information
Additional Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Consent & Authorization
I, the undersigned, hereby acknowledge and consent to DNA collection and testing services provided by Gray Positive Solutions LLC. I confirm that:
- I am voluntarily requesting DNA testing and authorize Gray Positive Solutions LLC and its laboratory partners to collect and process my (or the tested party’s) genetic sample.
- I have provided government-issued photo identification to verify my identity, and I understand that false or misleading information may invalidate the test results.
- I understand that deposits are 100% non-refundable, except if cancelled by Gray Positive Solutions LLC or by an authorized party within 72 hours of the scheduled test date.
- I agree that all mileage fees must be paid prior to dispatch at the rate of $0.62 per mile from headquarters (13601 Preston Rd Suite 215W Dallas, TX 75240).
- I understand that full payment is due on or before the day of collection.
- I acknowledge that test results will be delivered within approximately 5 business days via the email and mailing address provided on this form.
- I consent to the secure handling of my personal and medical information in compliance with HIPAA and applicable privacy laws.
By signing below, I certify that I have read, understood, and agree to the terms above, and I authorize Gray Positive Solutions LLC to proceed with DNA testing services.
Consent Questions
Do you understand that no additional guests are allowed during the collection?
❌ Collection cannot be scheduled unless you agree to the no-guest policy. Please contact our office if you have special circumstances.
Do you understand that we will bill you for any balances and mileage prior to coming out?
Disclaimer
- The information provided in this form will be used solely for the purpose of DNA testing services by Gray Positive Solutions LLC, backed by DNA Diagnostics Center.
- The deposit today is 100% non-refundable unless the DNA test is cancelled by Gray Positive Solutions LLC or by an official party within 72 hours of the scheduled test date.
- Full payment is due the day of the test. A payment link will be sent. If unpaid, a collector will not be dispatched.
- Mileage fees are due prior to dispatch. Rate: $0.62 per mile from headquarters (13601 Preston Rd Suite 215W Dallas, TX 75240).
- Results are sent via email and postal mail within 5 business days.
- We safeguard your privacy and do not share information without consent, except as required by law.
- By submitting this form, you acknowledge and agree to these terms.
Signature of Person Ordering Test
Date Signed

MonthDayYear
Date
Payment Authorization & Payment Section
By signing this application, you authorize Gray Positive Solutions LLC to charge your provided payment method for all DNA testing services, including balances and mileage fees. You acknowledge any additional charges related to the service will also be charged to the card on file.

By proceeding, you agree to these terms and conditions and authorize the transaction.
Select DNA Test Type & Payment
Please select the DNA testing service(s) you would like to order below.
You may also add any applicable add-on services such as mobile collection or extra certified copies.

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Gray Positive Solutions LLC – DNA Client Intake Form

Ordering Party Information

Test Participants

Party 1 (Child):

Party 2 (Parent/Relative):

Party 3 (Optional):

Medical / Collection Questions

Additional Contact Information

Consent & Authorization

Consent Questions

Disclaimer

Payment Authorization & Payment Section

Select DNA Test Type & Payment

My Products*

Credit Card

My Products