DNA Banking Deposit Form

Depositor Information Form

Depositor Information

* - required field

*Last name:
*First name:
Middle name(s) or initial:
*Date of Birth:
Deposit Number (if known)

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