Depositor Information Form


Depositor Information

First, we require you to provide some basic information about the person who will be banking their DNA (the Depositor). This is so that we can contact the Depositor.

* - required field

 *Last name:
*First name:
Middle name(s) or initial:
Maiden Name:
*Gender:
*Date of Birth:
*Street Address:
*City:
*State:
*ZipCode:
*Country:
*Phone Number(s) Home/Work:
Email Address:
Name of person who completed this Form (if other than Depositor):
Representative Information

Next, we require basic information about the Depositor's Representative. The Representative is the person who will control the Depositor's DNA if the Depositor becomes incapacitated or after the Depositor dies (see DNA Banking Contract). Please choose the Representative carefully. The Representative must be at least 18 years of age.

  *Last name:
  *Fist name:
Middle name(s) or initial:
Maiden Name:
*Street address:
*City:
*State:
*Zip Code:
*Country
*Phone number(s) home/work:
Email addrses:
*Relationship to donor:

Family Tree


Next, we request information about the Depositor's biological relatives (the family tree). Providing this information is not absolutely required for DNA Banking at PreventionGenetics, but is strongly recommended. Family tree (or genealogical) information can be very useful in DNA testing and in receiving optimal health care. This is because DNA molecules are passed on from one generation to the next. Note that the information should only be about the Depositor's biological relatives, not legal relatives such as step-parents or adopted children.

Please provide as much of the requested information as possible. However, it's all right if you don't know some (or even any) of this information.

Some people have done research (sometimes extensive research) on their family trees. If you have information beyond what is requested in this form, please contact PreventionGenetics so that we may capture and store this information for you.

We request the geoancestry of your grandparents. Knowing a person's geoancestry, or the geographic origin of the person's ancestors of about the time of Columbus (1500), can speed the identification of specific variant DNA sequences that the person carries. Examples of geoancestry include: German, Italian, Kenyan, Chinese, Hmong, Ashkenazi, Hispanic, Native American/Ojibwa. Many grandparents will have multiple origins. Please list all relevant information.

If individuals are married, please list married names throughout.

Parents of Depositor:

Father's Last Name:
Father's First Name:
Father's Birth Date or Year of Birth:
Mother's Last Name:
Mother's First Name:
Mother's Maiden Name:
Mother's Birth Date or Year of Birth:

Grandparents of Depositor

Father's Side

Grandfather's Last Name:
Grandfather's First Name:
Grandfather's Birth Date or Year of Birth:
Grandfather's Geoancestry:
Grandmother's last name:
Grandmother's first name:
Grandmother's maiden name:
Grandmother's Birth Date or Year of Birth:
Grandmother's Geoancestry:

Mother's Side

Grandfather's Last Name:
Grandfather's First Name:
Grandfather's Birth Date or Year of Birth:
Grandfather's Geoancestry:
Grandmother's last name:
Grandmother's first name:
Grandmother's maiden name:
Grandmother's Birth Date or Year of Birth:
Grandmother's Geoancestry:
Siblings (full and half) of Depositor
Total number of siblings:
Siblings
Children of Depositor
Number of children:
Children
Grandchildren of Depositor:
Total number of grandchildren:
Grandchildren

After you hit the "Submit" button, a print friendly version of your information will appear.   Please print a copy for your records.