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GenQuest
DNA Analysis
Laboratory
133 Coney Island Drive
Sparks
,
Nevada
89431
877-362-5227 or 775-358-0652
fax 775-358-0657
Email:
[email protected]
https://www.genquestdnalab.com/
Paternity
Screening Test Request
Person
requesting the test
_____________________________________________________
Address
____________________________________________________________________
__________________Zip ________
Phone
____________________________ Email
____________________________________
Mother
____________________________________
Signature_________________________
Child
______________________________________________
Alleged
Father ________________________________ Signature
_______________________
Please
indicate the race to be used in the testing:
Mother:
Caucasian ___ Hispanic___ Asian ___ African American ___ Other
______________
Alleged
Father: Caucasian ___ Hispanic___ Asian ___ African American ___Other
__________
All
information is held in strict confidence. Testing should complete in 7-10 days
after receipt of samples and payment. The test results from a paternity screening
test cannot be used in a court of law because the samples were not collected in
accordance with AABB standards.
I
request a paternity-screening test on the samples I have submitted or will
submit.
Signature
___________________________________________________ Date
_____/_____/_____
________________________________________________________________________________
Payment
information: Cost of the test is $85.00 per
sample
_____Payment
enclosed check or money order
____ Credit Card: Visa / Mastercard / American
Express (please
circle)
Card
Number _____________________________________ Expiration
Date__________________
Name
on card _____________________________________
Signature_________________________________________
Reporting
Addresses
List
names and addresses of report recipients (only one item below is
required):
□
–
Please mail results in a discreet envelope.
Name:________________________________
Name:________________________________
Address:______________________________
Address:______________________________
City/State/Zip:__________________________
City/State/Zip:__________________________
Email:________________________________
Email:_________________________________
Fax:__________________________________
Fax:__________________________________