Enter Your Order Number

See Notes Section Below to Learn Where to Find Your Order Number.
Enter the name of the DNA Test (s) Purchased

Name*

Email*

Phone Number*

Street Address*

City*

State*

Zip Code

Gender* FemaleMale

Date of Birth*

Current Body Weight (Pounds)*

Height (Inches)*

Comments

Note:

• If Purchased through our SHW Online E-Store, You Received an Order Number on Your Purchase Receipt.
• If Purchased through one of our Provider Partners, the Order Number will be written on your Requisition Form included within your Test Kit.

Regarding the phone or email consultation with our Physician, Pharmacist or Genomic Experts, the contents and recommendations are only given as an opinion and shall not constitute an official medical recommendation. Thus, the interpretation is given for information purposes only. Therefore, this information shall be interpreted in conjunction with other clinical findings and familial history under the guidance of your personal physician. Patients should seek appropriate health counseling from their doctor to explain the implications of this interpretation. Sole responsibility for the proper use of this information provided by Safe Harbour Wellness, their staff or associates, rests with the user, or those professionals with whom the user may consult outside of the Safe Harbour Wellness Team. Any information provided is not intended to diagnose, treat, cure or prevent a disease. These recommendations are for information purposes only, and an individual is not required to use such advice or products. These are recommendations only and do not replace the advisement of your own healthcare practitioner. By pressing submit, I acknowledge I have read this health consent form completely and agree to the terms outlined.