Minkoff Center for Jewish Genetics · Preconception Screening Registration

Registration Fee- With Insurance Provided *	Quantity
$200 - Couple Ages 36-45
$100 - Non-student between the ages of 36-45
$75 - Young Professional ages 25-35
$50 - Student/Financial Assistance Requested
$250 - **If you do not provide insurance

Get your test kit!

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I am available by phone. We will follow up with you by email to set up and over the phone appointment and mail your test kit!

Contact Information

Name

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First Name

Last Name

Email

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Verify Email

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Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone

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Date of Birth

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(mm/dd/yyyy)

Gender

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Are you pregnant?

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Will you be participating with a spouse or partner?

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If you will be participating with a spouse, please ensure you select the correct number of tests above.

Spouse/Partner Name

Spouse/Partner Date of Birth

(mm/dd/yyyy)

Partner's Email

Verify Email

Is it OK to share your carrier results with your spouse or partner?

Family History

NOTE: Accurate info about ancestral ethnic background and family history increases accuracy of test results.

Is/was your father of Eastern European Jewish ancestry?

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Is/was your mother of Eastern European Jewish ancestry?

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If yes, are you aware of any genetic diseases in your parent's lineage?

Are you aware of any relatives known to be carriers of any diseases?

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If yes, which disease(s)? How are they related to you?

Spouse Family History

NOTE: Accurate info about ancestral ethnic background and family history increases accuracy of test results.

Is/was your father of Eastern European Jewish ancestry?

Is/was your mother of Eastern European Jewish ancestry?

If yes, are you aware of any genetic diseases in your parent's lineage? Copy

Are you aware of any relatives known to be carriers of any diseases?

If yes, which disease(s)? How are they related to you?