Please complete the application to request your DNA Cancer Test.

HOW DOES IT WORK?
1. Your application will be reviewed for a valid insurance and patient history.
2. A medical staff member or doctor will contact you via phone to verify your family history and medical records.
3. Once the doctor approves your application, a DNA Cancer testing kit will be mailed to your address.
4. Follow the instructions provided in the package to complete the Screening Kit.
5. Fill out the consent form and return the screening kit using the provided mailing slip.
6. Once the lab receives your kit, the results will be available within approximately 3-4 weeks.

DNA CANCER TESTING APP:

AGENT ID:
Full Name:
D.O.B:
Sex:
Driver's License:
Height:
Weight:
Race:
Street Address:
City:
State:
Zip Code:
Email:
Home Phone:
Cell Phone:
Insurance Information
INSURANCE CARRIER:
Policy Number:
Last 4 Digits of Your SSN:
Primary Physicians Phone:
Primary Physicians Fax:
Primary Physicians Name:
Family Cancer History:
Check all family members who were diagnosed with cancer:
MomDadGrandmotherGrandfatherSisterBrotherAuntUncleNieceNephew

Have you ever been diagnosed with cancer:

Would you also like to receive a PGx test?
Find out if the medication your taking is causing harm in other areas of your health! PGx looks at how genetic makeup affects your body’s response to medications via drug-to-gene and drug-to-drug testing.

*100% cost covered by most insurances. Once your application is received you will be notified via email if your testing is completely covered by your insurance company. If NOT, your application will be denied and you will be notified via email.