DNA Profiling Request Form - Solicitors

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

County / State / Province / Region

Post / 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

County / State / Province / Region

Post / 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
Please state which test you require?

(e.g., paternity verification, sibship analysis, viability testing, grandparentage, etc.)
IF THE TEST REQUIRED IN QUESTION 1) IS A VERIFICATION OF EITHER PATERNITY OR MATERNITY, THEN PLEASE STATE IF A CLOSE MALE/FEMALE RELATIVE (e.g., BROTHER/SISTER) OF THE ALLEGED FATHER/MOTHER OF THE CHILD(REN) IN QUESTION IS POTENTIALLY THE TRUE BIOLOGICAL FATHER/MOTHER? 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 NOTE: If the answer to this question is “YES”, then we require a sample from the close relative, in addition to the one from the alleged parent.
Additional Information
IF THE TEST REQUIRED IN QUESTION (1) IS A SIBSHIP ANALYSIS THEN PLEASE STATE THE PURPOSE OF THIS TEST (e.g., to determine whether the individuals being tested share both parents, share one parent, are unrelated, etc.) FULL SIBLINGS (Share both parents) HALF SIBLINGS (Share one parents) UNRELATED
(Please note, if the appropriate allele frequency reference database is not available for the individuals tested, then the closest available reference database will be used for the purposes of statistical analysis)
IF SIBSHIP ANALYSIS DO THE INDIVIDUALS BEING TESTED SHARE THE SAME BIOLOGICAL FATHER? Yes No Possibly Don't Know
IF SIBSHIP ANALYSIS DO THE INDIVIDUALS BEING TESTED SHARE THE SAME BIOLOGICAL MOTHER? Yes No Possibly Don't Know
PLEASE INDICATE WHICH PRIORITY OF TEST YOU REQUIRE: STANDARD TEST - results in five (5) working days EXPRESS TEST - results in three (3) working days (Additional fee of £100.00 plus VAT) 24 HOUR TEST - results in one working day (Additional fee of £250.00 plus VAT)
Additional Information
IS THE TEST PURSUANT TO A COURT ORDER UNDER S20 FAMILY LAW REFORM ACT 1969? Yes No
Under S20 Family Law reform Act 1969, a Medical Practitioner / GP must be instructed to collect the samples. If Yes, please attach a copy of your Court Order (Essential, your case can not be progressed without this). If No, but you would prefer a Medical Practitioner / GP to collect the samples then please enter details below. Note: Alpha Biolaboratories will charge a fee for Kit Preparation, Dispatch of Kit and Arrangement of such. In addition the Medical Practitioner / GP have the right to make charges for their services, for which you will be directly responsible.
Please provide Medical Practitioner / GP details to send swab kits to:
Parties Name Title First Last Suffix
GP Name Title First Last Suffix
GP Address
Street Address

Address Line 2

City

County / State / Province / Region

Post / Zip Code

Country
Contact Number
Additional Information
DO YOU REQUIRE A COMPANY NURSE TO COLLECT THE RELEVANT SAMPLES FOR TESTING? Yes No
IS THE CHILD(REN) IN FOSTER CARE? Yes No
If yes, please provide either Social Worker and/or foster carers
Name Title First Last Suffix
CONTACT TELEPHONE NUMBER
IS THE CHILD(REN) SUBJECT OF AN INTERIM CARE ORDER/CARE ORDER? Yes No
If Yes, you will need to provide a copy (Essential)
STATEMENT OF WITNESS REPORT (please tick as appropriate) Yes No
Please Note: There is an additional fee of £100.00 plus VAT for this service.
PLEASE STATE THE COURT DATE FOR THIS CASE (if any): / DD / MM YYYY
DID YOU KNOW THAT WE OFFER A RANGE OF HAIR STRAND ANALYSIS SERVICES FOR THE DETECTION OF DRUGS AND ALCOHOL? Yes No
WOULD YOU LIKE SOME INFORMATION RELATING TO THESE SERVICES? Yes No
HOW DID YOU LEARN OF OUR SERVICE(S)?
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 - Solicitors

DNA Profiling Request Form - Solicitors

PLEASE COMPLETE ALL RELEVANT SECTIONS OF THE FOLLOWING FORM

Second Person for Analysis

Additional Information

PLEASE NOTE: If the answer to this question is “YES”, then we require a sample from the close relative, in addition to the one from the alleged parent.

Additional Information

Additional Information

Please provide Medical Practitioner / GP details to send swab kits to:

Additional Information

If yes, please provide either Social Worker and/or foster carers