Pink or Blue® Order Form – Complete, Detach, and Return With Your Sample Έληππν δηάηαμεο – ζπκπιεξώζηε, ππνγξάψηε, θαη επηζηξέψηε ην παξόλ έγγξαθν καδί κε ην δείγκα ζαο - Pink or Blue®
Please complete the form below, detach and return with your sample. All information on this form is required. Please visit www.abourkascompany.com for a full description of our testing and refund policies. Please write legibly. Results will be sent via email to A. Bourkas Company United: Email: abourkas@abourkascompany.com Πξώηε εκεξνκελία ηεο ηειεπηαίαο εκκελνξξνϊθήο πεξηόδνπ: First date of Last Menstrual Period: _____________________________________________________________ (ή θαη' εθηίκεζε νθεηιόκελε εκεξνκελία ηνπ κωξνύ or the baby’s estimated due date: _______________________________________________________________) Ήηαλ νπνηαδήπνηε αξζεληθά παξόλ θαηά ηε δηάξθεηα ηεο ζπιινγήο δεηγκάηωλ?: Were any males present during sample collection? NAI Yes Σπιιέμαηε ην δείγκα ζε έλα θαζαξό πεξηβάιινλ:: Did you collect sample in a clean environment?
OXI No
NAI Yes
OXI No
Consent to DNA Testing:
By signing below, I consent to this testing. I confirm that I have not had a pregnancy end within the last 3 months, I have not had a blood transfusion in the last 18 months and I have never had an organ or bone marrow transplant. I have followed all collection instructions. I understand that all materials and products provided by Consumer Genetics, Inc. are provided for informational purposes only and that I should consult with a physician or healthcare provider regarding any questions pertaining to fertility, pregnancy, breastfeeding, baby care, etc. I further recognize that this test does not replace a woman’s need to visit a doctor during pregnancy, or to have an ultrasound or other pregnancy-related tests performed. I understand that Consumer Genetics, Inc. is not liable for any damages caused to me or anyone else as a result of using this product. Furthermore, I assure that I am not using Pink or Blue® for reasons relating to gender selection. By making a purchase from Consumer Genetics, Inc., I agree to release, indemnify, and hold harmless all of its officers and employees from all liabilities associated with the product(s) purchased. I understand that Consumer Genetics, Inc. is not liable for any actions that might be taken by myself or anyone else as a result of using this service.
Mother’s Signature: Print Name:
Date:
A sample without a signature will NOT be processed.
Lab Use Only
Lot #
A. Bourkas Co.
Kit ID
Blood Collection Instructions & Order Form
pink or blue®
Girl or Boy? Find out early… Toll Free: 866-6-WHAT-R-U
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Consumer Genetics LAB, USA - 562 E. Weddell Dr., Suite 9 Sunnyvale, CA 94089 Tel: and Fax: +30 210 65 12 285
a.bourkas Co. United Group Of Consumer Genetics LAB, USA