Client Intake Form

Client Intake Form

Please provide your details to help us serve you better.
What is the primary reason you are seeking DNA testing?
Name of person who ordered the test

First NameLast Name
Male or Female
Name of person being tested (Test Participant 1):

First NameLast Name
Date of Birth (Participant 1)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Male or Female
Name of person being tested (Test Participant 2):

First NameLast Name
Date of Birth (Participant 2)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Male or Female
Name of person being tested (Test Participant 3):

First NameLast Name
Date of Birth (Participant 3)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Male or Female
Name of person being tested (Test Participant 4):

First NameLast Name
Date of Birth (Participant 4)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Male or Female
Email Address Where Results will be sent
example@example.com
Your Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Phone Number
example@example.com
Your Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Please add any additional information below.
Has any test participant received a blood transfusion or bone marrow transplant within the last 90 days?
Please avoid eating, drinking, smoking, or chewing gum for at least 30 minutes prior to sample collection. If you need any assistance please call 203-405-9227.
* By signing, I consent to DNA collection and testing

** By signing below, I confirm I have reviewed and agree to all policies, terms and conditions at https://www.origindnatesting.com/terms-and-conditions

***I affirm that I am the parent or legal guardian of any minor listed on this form and that I have full legal authority to consent to DNA testing for each minor participant. I understand that no sample from a minor may be submitted without the consent of a parent or legal guardian.
Signature of Participant 1 or The Next Of Kin allowing DNA Collection
Signature of Participant 2 or Legal Guardian if participant is under 18 years old.
Signature of Participant 3 or Legal Guardian if participant is under 18 years old.
Signature of Participant 4 or Legal Guardian if participant is under 18 years old.
At Origin DNA Testing, We value your privacy and handle all DNA samples with care and confidentiality. Thank you for choosing us. We’re always available to discuss your results and answer any questions along the way.

Please call or text us for assistance

(203) 405-9227

****Origin DNA Testing is not a medical practice.
Should be Empty:

Client Intake Form

Please avoid eating, drinking, smoking, or chewing gum for at least 30 minutes prior to sample collection. If you need any assistance please call 203-405-9227.