Genex Diagnostics - Premium DNA Testing Services
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Legal Testing Booking Form for Healthcare Professionals
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Physician Information
First Name
Last Name
Address
City
State / Province
Zip / Postal Code
Country
Phone
E-mail
Name of Patient
Reason for Referral To relieve stress and anxiety due to uncertainty about paternity
  To resolve paternity for family involvement and support
  Other (please specify below)
 
Patient Information
  Alleged Father Mother Child #1 Child #2
First Name
Last Name
Middle Name
Address
City
State / Province
Zip / Postal Code
Country
Phone
Date of Birth (yyyy-mm-dd)
Preferred City for Collection
Note: Please click the check box beside Mother or Child #2 to fill in the required information if applicable.
Result Report Information
Recipient of Result Report Alleged Father Child #1 Physician
  Mother Child #2  
  Other (Please specify name, relationship, and address below)
 
Payment Information
Credit Card Visa    MasterCard  
Card Number - - -
Expiry Date (mm) / (yy)
CVC Number
Cardholder Name
Note: Please select the method of payment. Credit cards only for online orders. To pay by cheque or international money order, call 1-888-262-2263 or download the printable test request form to order by mail.
Additional Information
Notes
Contact Information
United States - Head Office

(Serving patients in all 50 states)
Genex Diagnostics
#180 - 4616 25th Avenue NE
Seattle, WA 98105
United States
International
Genex Diagnostics
#101 - 1001 W. Broadway, Dept.600
Vancouver BC V6H 4E4
Canada
Toll Free: 1-888-262-2263
Email: staff@genexdiagnostics.com
Internet: http://www.genexdiagnostics.com
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