Patient Self-Referral Form

Welcome to

InformedDNA

Empowering Personalized Healthcare

Important!: This page is used for prospective patients to self-register for genetic counseling. If you have been referred as a new patient, you will receive a username and password sent to your email address. If you have a username and password, please enter that information by clicking here. For questions about our patient portal, or if you are having trouble logging in, please contact us at 800-975-4819.

New Patient Self Referral

Patient Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email Address

Primary Phone*

Home Phone

Work Phone

Birth Date*

Sex*

Language*

Healthcare Provider

Providing this information allows your healthcare provider to get a copy of any genetic counseling or testing records after your appointment. This is important information to include in your medical care.

Responsible Party for Payment

Patient

Other:

Primary Insurance Card Holder

Patient Same as Responsible Party for Payment

Other:

Primary Insurance

Address (see back of card)

Address Line 1

Address Line 2

City

State

ZIP Code

Insurance ID #

Group ID #

Group Name

Purpose of Visit*