greatfulearthtest

Saliva Specimen Submittal Form

Client Information (please print / confidential)

Last Name or number: ____________________ First Name, MI: (opt): ___________________

Address (opt): _______________________________________________________________

Age: _______ Sex (M/F): _______ Weight (lbs): ____________ Height (ft., in): _____________

Email: _____________________________________________ Date: ____________________

Tel. #: _____________________________ Blood Type (optional): ______________________

Name of Doctor / Health Care Provider: _____________________________________________

Quantity: __________

***Please include saliva specimen with this questionnaire. ***

Instructions for Apolipoprotein E / ApoE Genome Test Saliva Collection

Wait 15 minutes after eating. Rinse mouth with plain water. Swallow normally for 15 minutes.

Remove the circle of filter paper from the plastic bag. Write your full name on the outside edge of the filter paper with a ballpoint pen. Print your name and (if applicable) your physician’s name on the blank white label on the plastic bag.

Collect at least a dime-size mouthful of saliva and put it directly onto the center portion of the filter paper. This is the minimum requirement. More saliva is acceptable.

Air-dry the filter paper for 1-3 hours until completely dry. Put the filter paper back into the plastic bag.

Enclose the return envelope and the plastic bag containing the filter paper specimen in the Graceful Earth Inc. envelope provided and mail.