DNA Profiling Request Form - General Public

PLEASE COMPLETE ALL RELEVANT SECTIONS OF THE FOLLOWING FORM
Relationship
Gender

Please select Gender
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date of Birth / DD / MM YYYY
Racial Origin
Telephone Number (Essential)
Medical History

Please give details of any known genetic diseases or recent infectious diseases.
Agreement Yes
I AGREE to have my samples analysed for the purposes of establishing the family relationship. I also indemnify and hold Alpha Biolabs harmless against any loss or damage, direct or indirect, for either the results obtained or for any action arising or taken by any person in receipt of the information, howsoever caused and accept your terms and conditions which are incorporated into this contract.
Second Person for Analysis
Relationship
Gender

Please select one option
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date of Birth / DD / MM YYYY
Racial Origin

Afro-Caribbean/Caucasian/Chinese-Asian/Indian-Asian/Other – Please specify
Telephone Number (Essential)
Medical History

Please give details of any known genetic diseases or recent infectious diseases.
Agreement Yes
I AGREE to have my samples analysed for the purposes of establishing the family relationship. I also indemnify and hold Alpha Biolabs harmless against any loss or damage, direct or indirect, for either the results obtained or for any action arising or taken by any person in receipt of the information, howsoever caused and accept your terms and conditions which are incorporated into this contract.
Additional Information
IS A CLOSE MALE RELATIVE POTENTIALLY THE BIOLOGICAL FATHER? Yes No
PLEASE NOTE: If Yes, then we require a sample from the close male relative, in addition to the one from the alleged parent.
Please state which test you require?
Type of Test? Peace of Mind Test? Court Admissable Test?
DO YOU REQUIRE SAMPLE COLLECTION APPOINTMENTS? Yes No
PLEASE SPECIFY THE COURT DATE IF APPLICABLE: / DD / MM YYYY
IS THE MOTHER SUPPLYING A SAMPLE? Yes No
PLEASE PROVIDE US WITH A CONTACT TELEPHONE NUMBER
HOW DID YOU LEARN OF OUR SERVICE(S)?
Report Distribution
PLEASE SEND MY RESULTS TO THE FOLLOWING ADDRESS:
Name Title First Last Suffix
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
PLEASE PROVIDE A PASSWORD TO ENSURE CONFIDENTIALITY

CHOOSE A PASSWORD THAT YOU CAN REMEMBER AS YOU WILL HAVE TO QUOTE IT EVERY TIME YOU CONTACT US. WE CANNOT DISCUSS YOUR CASE OVER THE TELEPHONE WITHOUT IT.
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DNA Profiling Request Form - General Public

DNA Profiling Request Form - General Public

PLEASE COMPLETE ALL RELEVANT SECTIONS OF THE FOLLOWING FORM

Second Person for Analysis

Additional Information

Report Distribution

PLEASE SEND MY RESULTS TO THE FOLLOWING ADDRESS: