Phone: (715) 387-0484

* - Denotes a required field.

DNA Banking Initiator Information

This is the person who is ordering DNA Banking by completing this form. In many cases, this is also the depositor (the person who is banking DNA), but it can also be a power of attorney or health care professional.


Address

Contact Info


Banking Depositor Information



Depositor 1 Info

The depositor is the individual whose DNA is being banked.



Address

(May be used later for mailing kit)

A Certificate will be sent to this address

Contact Info

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Sample Type and Kit Sendout Information





Cultured cells and tissue samples can be used for DNA Banking purposes, however no kit is provided for these specimen types. Please see our Specimen Types for DNA Banking page for specimen guidelines. Include a copy of the confirmation receipt at the end of this registration when mailing the specimen to PGDNABank.

Please contact us for assistance.

Email: dnabanking@preventiongenetics.com

Phone: (715) 387-0484

Please specify your healthcare provider's information in case we need to contact them with questions about your request.

Please provide your information in case we need to contact you with questions about your client's request.


The kit will be sent to the address specified under Depositor 1 Information

Maternal specimen is recommended for contamination studies. Please see our Specimen Types for DNA Banking page for details.

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Representative 1 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 2 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 3 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 4 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 5 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 6 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 7 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 8 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 9 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 10 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 11 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 12 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 13 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 14 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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Representative 15 for Depositor 1

A representative is a trusted individual who will control the Depositor's DNA in the event they become incapable of managing their affairs or are deceased. Multiple representatives can be listed for a single depositor.


Address

Contact Info

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DNA Banking Agreement for Depositor 1


Healthcare providers or those assisting others with DNA Banking cannot sign the DNA Banking agreement on behalf of the depositor. The depositor or their legally authorized representative MUST be present and electronically sign the agreement. For questions or concerns, please contact us.

Email: dnabanking@preventiongenetics.com

Phone: (715) 387-0484

The DNA Banking Agreement contains provisions for banking of a person's (depositor's) DNA. By signing the Agreement, you the Depositor, give authority to PreventionGenetics to extract and store your DNA. Further, you have provided the names of authorized individuals who may request PreventionGenetics to withdraw your DNA from the bank.

The parties agree that this document may be electronically signed. The parties agree that the electronic signature appearing on this agreement is the same as the hand-written signature for the purposes of accessibility, authority, enforceability, and admissibility.


The DNA Banking Agreement contains provisions for banking of a person's (depositor's) DNA. By signing the Agreement on behalf of the depositor, you give the authority to PreventionGenetics to extract and store the DNA. Further, you have provided the names of authorized individuals who may request PreventionGenetics to withdraw the DNA from the bank.

The parties agree that this document may be electronically signed. The parties agree that the electronic signature appearing on this agreement is the same as the hand-written signature for the purposes of accessibility, authority, enforceability, and admissibility.

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Depositor 2 Info

The depositor is the individual whose DNA is being banked.



Address

(May be used later for mailing kit)

A Certificate will be sent to this address

Contact Info

You have completed this section! Continue to the next section

Sample Type and Kit Sendout Information





Cultured cells and tissue samples can be used for DNA Banking purposes, however no kit is provided for these specimen types. Please see our Specimen Types for DNA Banking page for specimen guidelines. Include a copy of the confirmation receipt at the end of this registration when mailing the specimen to PGDNABank.

Please contact us for assistance.

Email: dnabanking@preventiongenetics.com

Phone: (715) 387-0484

Please specify your healthcare provider's information in case we need to contact them with questions about your request.

Please provide your information in case we need to contact you with questions about your client's request.