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