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Legal Counsel Requisition Package.p65
Note: Genetrack has over 500 specimen collection facilities across Canada. Refer to Collection Location list when completing this form. SHADED AREA IS FOR LAB USE ONLY Serving the medical and legal communities across Canada. Laboratory Requisition for Cases Involving Legal Counsel - DNA PATERNITY TESTING Toll Free Fax: 1-888-655-8877 Fax: (604) 325-2208 Toll Free Tel: 1-888-828-1899 Tel: (604) 325-7282 Le g a l Bi o m e d i c a l Se r v i c e s GENETRACK BIOLABS M e d i c a l DNA Te st i n g Se rv i c e s Genetrack Biolabs Molecular Diagnostic Laboratory 401 - 1508 West Broadway Vancouver, BC V6J 1W8 First Initial(s) Fax Fax Date of Birth Date of Birth 1. To initiate testing, complete this form and submit to Genetrack by Fax at 1-888-655-8877 or mail. Upon receipt, the laboratory will contact the patients directly (unless otherwise specified) with appointment times. Appointments can also be scheduled through the national booking number at 1-888-828-1899. 2. Appointments are approximately 15 minutes in duration. Blood and buccal swab (painless mouth swab) options are available at most locations. 3. Results are available 3 to 5 days after testing begins. All results will be reported as either 0% for paternity exclusion, or greater than 99.9% for paternity inclusion. Results are legal documents. 4. The cost for a complete DNA paternity test is $580.00 +GST (this cost is all inclusive, and includes all specimen collection, transport and laboratory fees). Please note that this special rate is applicable for all cases ordered through legal counsel. PART 1 - PATIENT INFORMATION Mother Surname Postal Code Address City, Province Initial(s) Preferred city for sample collection First Phone/Fax Child Surname Postal Code Address City, Province Initial(s) Preferred city for sample collection First Phone/Fax Alleged Father Surname Postal Code Address City, Province Preferred city for sample collection Initial(s) Postal Code First Phone/Fax Surname Other (Please specify) City, Province Preferred city for sample collection Address Phone/Fax Name/Firm Alleged Father’s Representative Address PART 2 - REPRESENTATIVES Mother’s Representative Address Phone City, Province, Postal Code Name/Firm Fax City, Province Representing (circle one): M / C / AF City, Province, Postal Code Phone Other Address Phone Name/Firm Postal Code Court Date (if applicable) PAYMENT INFORMATION The complete cost to test a mother, child, and alleged father (or with a single parent) for cases involving Legal Counsel is: $580.00 (+GST, if applicable). This rate is all inclusive and includes the sample collection fees. The cost to test each additional individual (e.g. child #2, alleged father #2) is $260.00 (+GST, if applicable). Includes all sample collection, transport and laboratory fees. Please indicate method of payment: Payment Enclosed. Amount $ Payment is held in trust. Please attach a letter of authorization from the appropriate legal representative. Amount $ Please contact the client directly to arrange payment. Other (please specify) GTB-RLC 1.2 (exp 12/2004) Genetrack Biolabs - Medical Collection Locations WESTER N C AN AD A EASTER N C AN AD A B R ITISH C OLU MB IA Abbotsford Anahi m Lake Barri ere Bella C oola Burnaby C ampbell Ri ver C astlegar C hetwynd C hi lli wack C loverdale C oqui tlam C ourtenay C ranbrook C reston D awson C reek D elta/Tsawwassen D uncan Elkford Ferni e Fort Nelson Fort St. James Fort St. John ALB ER TA Athabasca Banff Barrhead Bashaw Blai rmore Bonnyvi lle Bow Island Brooks C algary C amrose C astor C oaldale C old Lake C oleman D i dsbury D rayton Valley D rumheller Eckvi lle SASK ATC H EWAN C arrot Ri ver C ut Kni fe Estevan Hudson Bay Indi an Head Kamsack Ki ndersley MAN ITOB A Altona Ashern Beausejour Brandon C artwri ght ON TAR IO Ajax Fort Eri e Alexandri a Fort Frances Alli ston Georgetown Ancaster Guelph Ati kokan Hali burton Aurora Hami lton Bancroft Hanover Barri e Hawkesbury Bellevi lle Hearst Huntsvi lle Bolton Bracebri dge Ignace Bramalea Ingersoll Brampton Iroquoi s Falls Brantford Kapuskasi ng Brockvi lle Kemptvi lle Burli ngton Kenora C ambri dge Ki ngston C hatham Ki tchener C obourg Leami ngton C ochrane Li ndsay C olli ngwood Li stowel C ornwall London D ownsvi ew Malton D ryden Markham D urham Mi dland Elli ot Lake Mi lton Etobi coke Mi ssi ssauga Exeter Napanee QU EB EC C hateauguay D ollard-des-Ormeaux N EW B R U N SWIC K Bath D i eppe Bathurst Edmundston Blacks Harbour Eel Ri ver C rossi ng Blackvi lle Frederi cton C ampbellton Grand Bay C hatham Mi rami chi C hi pman Moncton N OVA SC OTIA Amherst D i gby Anti goni sh Falmouth Bedford Glace Bay Bri dgewater Hali fax Blockhouse Kentvi lle C heti camp Ki ngston D artmouth Li verpool PR IN C E ED WAR D ISLAN D C harlottetown Montague N EWFOU N D LAN D Bai e Verte Gander Bonavi sta Glovertown Burgeo Grand Falls C artwri ght Happy Valley GB C larenvi lle Harbour Breton C orner Brook Head of Bay d'Espoi r D e e r L a ke Holyrood F ogo Hopedale Fortune Labrador C i ty Fraser Lake Ganges Gi bsons Golden Grand Forks Hazelton Hope Hornby Island Houston Invermere Kamloops Kaslo Kelowna Keremeos Ki mberley Ki ti mat Ki tkatla Klemtu Langley Li llooet L o g a n L a ke Mackenzi e Maple Ri dge Masset McBri de Nakusp Nanai mo Nelson New D enver North Vancouver Oli ver Osoyoos Pemberton Penti cton Port Alberni Port Hardy Powell Ri ver Pri nce George Pri nce Rupert Pri nceton Queen C harlottes Quesnel Ri chmond Salmon Arm Sechelt Smi thers Sparwood Stewart Summerland Surrey Terrace Tofi no Trai l Tumbler Ri dge Valemount Vancouver Vanderhoof Vernon Vi ctori a Whi stler Whi te Rock Wi lli ams Lake 100 Mi le House Edmonton E d so n Evansburg Fort C hi pewyan Fort McMurray Fort Saskatchewan Gi bbons Grande Prai ri e Gri mshaw Hanna Hi gh Level Hi gh Prai ri e Hi nton Inni sfai l Lac La Bi che Lacombe Leduc Lethbri dge Lloydmi nster Manni ng Mayerthorpe McLennan Medi ci ne Hat Olds Peace Ri ver Ponoka Provost Red D eer Redwater Ri mbey Rocky Mtn. House Ryley Sherwood Park St. Albert St. Paul Slave Lake Smoky Lake Spruce Grove Stettler Sundre Sylvan Lake Swan Hi lls Taber Valleyvi ew Vegrevi lle Vermi li on Vi ki ng Wabasca Wai nwri ght Westlock Wetaski wi n Whi tecourt Ki pli ng La Loche La Ronge Lloydmi nster Meadow Lake Melfort Moose Jaw Moosomi n Ni pawi n North Battleford Pri nce Albert Regi na Saskatoon Swi ft C urrent Weyburn Wi lki e Wollaston Lake Yorkton C hurchi ll D auphi n Fli n Flon Morden Morri s Norway House Portage La Prai ri e Souri s Swan Ri ver The Pas Thompson Vi rden Wi nkler Wi nni peg FEE SCHEDULE: FOR CASES INVOLVING LEGAL COUNSEL Complete DNA paternity test (mother, child, alleged father): $580.00 (includes all sample collection costs) Motherless DNA paternity test (child, alleged father): $580.00 (includes all sample collection costs) Each additional individual tested at the same time (e.g. child #2, alleged father #2): $260.00 Each additional individual tested at a later date: $372.00 Includes all sample collection, transport and laboratory fees. The reduced rates in this fee schedule are applicable for tests involving legal counsel. New Hamburg New Li skeard Newmarket Ni agara Falls Ni pi gon North Bay North York Oakvi lle Orangevi lle Ori lli a Oshawa Ottawa Owen Sound Parry Sound Pembroke Peterborough Port C olborne Port Hope Red Lake Renfrew Rexdale Ri chmond Hi ll Sarni a St. Thomas Sault Ste. Mari e Scarborough Si mcoe Smi ths Falls Southampton St. C athari nes Stayner Stoney C reek Stouffvi lle Stratford Strathroy Sudbury Thornhi ll Thorold Thunder Bay Ti llsonburg Ti mmi ns Toronto Trenton Uxbri dge Vi rgi l Walkerton Wallaceburg Waterloo Wawa Welland Wi llowdale Wi ndsor Woodbri dge Woodstock Laval Montreal Newcastle Oromocto Perth-Andover Sackvi lle St.-A.-de-Madawaska Sai nt John St.-Loui s-de-Kent Sai nt Stephen Sussex Tracadi e Wi lsons Beach Woodstock Meteghan New Glasgow Pi ctou Sackvi lle Shelburne Sydney Sydney Mi nes Tatamagouche Trenton Truro Wi ndsor Yarmouth Souri s Summersi de Makkovi k Mary's Harbour Marystown Mi lltown Newtown Norri s Poi nt Port aux Basques Port Hope Si mpson Recontre East Roddi ckton Spri ngdale St. Anthony St. Brendan's St. John's Stephenvi lle Stephenvi lle C rossi ng Twi lli ngate Wi ndsor Rae Ranki n Inlet Watson Lake Whi tehorse Yellowkni fe N OR TH ER N C AN AD A C ambri dge Bay D eli ne Faro Fort Smi th Hay Ri ver Inuvi k Iqalui t Norman Wells *PCR (polymerase chain reaction) technology is utilized for all paternity tests. *Prenatal paternity testing (chorionic villus sampling, amniocentesis) - contact the laboratory for instructions.
