50,000 Safer: Get Tested

Your Name *

First

Last

Your Email Address *

This will only be used to communicate with you about the 50,000 Safer program.

Your Phone Number

State of Residence *

Enter the state of residence for the person(s) who needs pharmacogenetic testing.

How would you prefer we contact you if there are any questions with your sign up? (check all that may apply)

Email
Phone
Text message
No preference

Who is the pharmacogenetic test for? (check all that apply) *

Myself
Family Member(s)
Client or Patient (if you are a healthcare or social service provider)
Other (friend, neighbor, church member, etc)

Have you read our program eligibility page? *

Yes
No

If you have not read the information on our website about program eligibility, we strongly suggest that you do that BEFORE completing this form. Unfortunately, certain individuals with a history of organ transplant, liver transplant, whole blood transfusion or recent bone marrow treatment may NOT benefit from pharmacogenetic testing. The eligibility page explains this in more detail.

The 50,000 Safer program is a voluntary free support program and is not a research study. Please check "yes" to confirm your, or the patient's, understanding and continued interest in participating. *

Yes

If you are signing up behalf of someone, please make sure you read this statement to them and gain their consent to participate before checking "yes". If you need more information before completing this section, please email us at contact@safestdrug.org.

After completing this sign up, we will mail the patient a 50,000 Safer program welcome letter with support information. Where should we send those materials? (please provide a mailing address) *

A member of our program support team will aim to send the welcome information within 1 to 5 business days.

If you or the person who needs a pharmacogenetic test has any special language needs, please provide those details (leave blank or type "N/A" if English is the primary language):

How did you hear about the 50,000 Safer program?