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Who parties Be
Who is ordering the test?
*
First
Last
Phone Number
*
Additional Party Phone Number
Who is being tested? (Child's first and last name)
*
First
Last
Date Of Birth
*
Address of testing party 1:
*
Address of testing party 2:
Location Type
*
Residential
Commercial
Public Place
Email Where Results Will Be Delivered
*
Is this a prenatal test
Yes
No
Are there any lingering domestic issues preventing the parties fr?om being tested in the same room
Yes
No
Submit
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