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Legal Testing Booking Form for Lawyers or Legal Counsels
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Booking 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.
Legal Representative Information
  for Alleged Father for Mother for Child #1 for Child #2
First Name
Last Name
Firm Name
Address
City
State / Province
Zip / Postal Code
Country
Phone
Fax
Note: Please click the check box beside for Mother or for Child #2 to fill in the required information if applicable.
Payment Information
$ is held in trust for (choose all that apply): Alleged Father Mother Child #1 Child #2
Please contact the client(s) directly to arrange payment (choose all that apply): Alleged Father Mother Child #1 Child #2
Credit Card Visa    MasterCard  
  Card Number - - -
  Expiry Date (mm) / (yy)
CVC Number
Cardholder Name
Other arrangement (please specify below)
 
Note: The complete cost to test a mother, child and alleged father (or with a single parent) involving Legal Counsel is $325.00 US. The rate is all inclusive. The cost to test each additional individual (e.g. Child #2, Alleged Father #2) is $160.00 US. Includes all sample collection, transport and laboratory fees.
Additional Information
Court Date yyyy mm dd
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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