DNA Ancestry Analysis Test Requisition Form
1. Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Address
Phone
Email
2. Test Requested
Test Type
Select
Y-Chromosome (Paternal Line)
mtDNA (Maternal Line)
Autosomal DNA
Other
Reason for Testing / Relevant History
3. Specimen Information
Specimen Type
Saliva
Buccal Swab
Blood Sample
Other
Collection Date
Collected By
4. Reporting Physician / Clinician Information
Name
Phone
Email
5. Consent
Patient/Guardian Name
Date
Signature