Twin or Triplet Zygosity Test - Order Form

Results of the test will be mailed within 10 business days of our receiving the DNA collection kits. With check, money order, or credit card information, mail this form to: Proactive Genetics, Inc., 149 Davis Road, Suite C, Augusta GA 30907 USA. Order securely online at www.proactivegenetics.com.


DNA Testing Services and Shipping Methods:
Testing Services Fee per set of multiples Shipping Options (check one) Fee per order
Twin Zygosity Test $139.00 USPS First Class Mail (U.S. only) FREE!
Triplet Zygosity Test $199.00 USPS Priority Mail (U.S. only) $15.00
    CANADA: International Mail $20.00
    International Delivery (all other countries) $25.00
Person requesting the test:
Name: ______________________________________________
Street Address: ______________________________________________
City/State/Zip: ______________________________________________
Telephone: ______________________________________________
E-mail Address: ______________________________________________
Relation to the multiples: (check one)  parent/guardian      one of the multiples     relative   friend
Multiples age:     ___________
Shipping preference: (check one)      to yourself     to the multiples
Where did you hear about us? ____________________________________________
Multiple #1: (please enter address information only if different from above)
Full Name: ______________________________________________
Street Address: ______________________________________________
City/State/Zip: ______________________________________________
Telephone: ______________________________________________
Multiple #2: (please enter address information only if different from above)
Full Name: ______________________________________________
Street Address: ______________________________________________
City/State/Zip: ______________________________________________
Telephone: ______________________________________________
Multiple #3: (please enter address information only if different from above)
Full Name: ______________________________________________
Street Address: ______________________________________________
City/State/Zip: ______________________________________________
Telephone: ______________________________________________
Method of Payment:
Check One: Check/Money Order Visa Mastercard American Express Discover
Name on card: ______________________________________________    
Card number: ______________________________________________ Expiration date: ________________
Note: Checks and money orders should be made payable to "Proactive Genetics, Inc."
Terms and Conditions:
I understand that Proactive Genetics is committed to providing accurate and affordable genetic testing services in a safe and secure manner. I understand that while the results of the tests conducted by Proactive Genetics are 99% accurate, these results must only be used for informational purposes and that the results are not qualified for any medical or legal purposes.