Home Paternity Testing Kit Order Form

"*" indicates required fields

Step 1 of 4

How many people testing*

Number of people that will be providing a sample.

Number of Shipping Addresses*

Shipping Options*

Number of Shipping Addresses*

Shipping Options*

Number of Shipping Addresses*

Shipping Options*

A $6.00 handling fee is added for standard shipping to any additional address.

Coupon

Total

Shipping Name*

First Last

Shipping Address*

Street Address Apt/Ste City State ZIP Code

Shipping Name #2*

First Last

Shipping Address #2*

Street Address Apt/Ste City State ZIP Code

Shipping Name #3*

First Last

Shipping Address #3*

Street Address Apt/Ste City State ZIP Code

Participant #1

Name*

First Last

Testing As*

Date of Birth*

Shipping Address*

Participant #2

Name*

First Last

Testing As*

Date of Birth*

Shipping Address*

Participant #3

Name*

First Last

Testing As*

Date of Birth*

Shipping Address*

Participant #4

Name*

First Last

Testing As*

Date of Birth*

Shipping Address*

Pin Number*

This pin number will be used to verify your identity later when receiving results. The contact person will be required to provide this information to receive results. If you are not the contact person please share this information with the main contact person.

Extra Information

Add any extra relevant information related to your order.

Contact Name*

First Last

Contact Phone*

Contact Email*

Payment Method*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date CCV Cardholder Name

Billing Address*

Street Address City State ZIP Code

Please note that the card billing address must match the address on record with the credit card company where your statements are sent.

Total

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