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Non-Legal DNA Test Authorization Form
The DNA Identity Testing Laboratory of Bio-Synthesis, Inc. is Accredited by the AABB.
612 E. Main Street, Lewisville, Texas 75057

Tel: (800)DNA-EXAM ; (888)786-9323  ;  (972)420-8505 (Outside US)

Fax: (972) 420-0442 Email: DNAtest@800dnaexam.com
  For accurate results, it is extremely important to fill out each section of the form properly.
CASE#:

PREPAID
YES NO
  Relationship #1
Mother Father Child Sister Brother
Aunt Uncle Grandmother Grandfather    
 
  Name: 

(First Name) (Middle Initial) (Last Name) (Maiden Name)
  Date of Birth:
Date Sample was collected:
  Race :
Caucasian Black Hispanic Asian   Other  
Sex: M F
 
  Notes:

  Relationship #2
Mother Father Child Sister Brother
Aunt Uncle Grandmother Grandfather    
 
  Name: 

(First Name) (Middle Initial) (Last Name) (Maiden Name)
  Date of Birth:
Date Sample was collected:
  Race :
Caucasian Black Hispanic Asian   Other  
Sex: M F
 
  Notes:

  Relationship #3
Mother Father Child Sister Brother
Aunt Uncle Grandmother Grandfather    
 
  Name: 

(First Name) (Middle Initial) (Last Name) (Maiden Name)
  Date of Birth:
Date Sample was collected:
  Race :
Caucasian Black Hispanic Asian   Other  
Sex: M F
 
  Notes:

  Relationship #4
Mother Father Child Sister Brother
Aunt Uncle Grandmother Grandfather    
 
  Name: 

(First Name) (Middle Initial) (Last Name) (Maiden Name)
  Date of Birth:
Date Sample was collected:
  Race :
Caucasian Black Hispanic Asian   Other  
Sex: M F
 
  Notes:

  Important: Please read entire instruction sheet before beginning. Collect ONLY one person’s sample at a time.
   
Step 1 Rinse mouth three times with warm water.
Step 2 Remove a sterile cotton swab from the original Pur- Wraps® package. DO NOT TOUCH SWAB TIPS WITH YOUR FINGERS.
Step 3 In a circular or twisting motion, rub the swab firmly against the inside of cheek, 8-10 times. Repeat Step 2 –3 with the second and third swabs.
Step 4 Place all 3 swabs into the original package and then into the appropriate color coded and /or numbered envelope. DO NOT USE PLASTIC BAGS OR SEALED TUBES.
Step 5 Label and initial each envelope properly and return complete
kit (authorization form, disclaimer and samples) to:
 

Bio-Synthesis, Inc.
DNA Identity Testing Coordinator
612 E. Main Street
Lewisville, TX 75057
  PAYMENT INFORMATION:
  I. If you choose to pay by money order or cashier’s check, make payable to BIO-SYNTHESIS, INC.    and use return envelope enclosed.

II. If you choose to pay by CREDIT CARD, please complete the following:
 

Amount Due:

Credit Card Type:

 VISA Master Card AMEX Discover Debit Card w/VISA or MC Logo
 
Credit Number: Expiration Date:
Amount Authorized: 
Security Code:

3 or 4 digits in front/back of the card
Name as it appears on the card: Cardholder’s phone:
 
Cardholder’s Billing Address:

 
  I hereby give permission to Bio-Synthesis, Inc. to charge the above account for the amount of service(s) requested.
 
     
     
(Signature of Cardholder)   (Date Signed)
 
  All information on this form will be used solely for this family relationship analysis. No other agency or outside party(s) will have access to this information without your written, notarized consent or without legal process.
 
DISCLAIMER
 
  Please read the following statement. This document must be returned with test samples. If you have any questions, please call 972-420-8505 ext. 100 or toll free 1-800-362-3926 ext. 100.

1. Errors can, and sometimes do, occur in DNA testing;

2. Bio-Synthesis, Incorporated makes no warranty, either express or implied, with respect to the goods or services provided in connection with this kit or the DNA test, or with respect to the results, whether as to merchantability or fitness for a particular
purpose;

3. Bio-Synthesis, Incorporated shall not be responsible for any direct, indirect, consequential, punitive or incidental damages of any kind whatsoever, with respect to the DNA service provided, whether arising out of or related to the DNA testing, the DNA
kit or the accessories to the kit, or any part thereof;

4. If you believe an error has occurred in testing, you will contact Bio-Synthesis Incorporated immediately, giving Bio-Synthesis, Incorporated a reasonable opportunity to remedy any deficiencies;

5. In the event of any errors in handling or testing the samples submitted by you for DNA testing, YOUR SOLE AND EXCLUSIVE REMEDY AGAINST BIO-SYNTHESIS IN CORPORATED SHALL BE EITHER A REFUND OF THE MONIES PAID BY YOU TO BIOSYNTHESIS INCORPORATED, OR COMPLETION OF A SECOND TEST AT THE EXPENSE OF BIOSYNTHESIS INCORPORATED, SUCH REMEDY TO BE ELECTED BYBIO-SYNTHESIS INCORPORATED, AT ITS DISCRETION.


By signing below you indicate your agreement to the terms and conditions, and limitations of liability, contained above, and request that Bio-Synthesis, Incorporated perform DNA testing on the enclosed samples.

Agreed:
       
Print Name/Date Signature
       
Print Name/Date Signature
       
Print Name/Date Signature
  Up to two (2) original reports per test, mailed via standard U.S. mail.
  I authorize Bio-Synthesis, Inc. to release the test results to: **Please print clearly**
       
       
       
View Results Online* View Results Online *
  Email:     Email:    
  Password:     Password:    
  * Your email address must first be authenticated by a case consultant the, you will receive instructions via email for where and how to view your results.  Create an alphanumeric password, 6-8 characters.