Justice DNA Access Intake

Full Name *

Email:___________________________
Phone:________________________ Preferred :
Phone ☐ Email ☐ Text

Do you consent to DNA collection and interpretation through rezultz? *

Yes
No

Do you identify with any of the following? *

Black/African American
Indigenous/Native
Afro- Indigenous
Latinx
Disabled
Caregiver
LGBTQIA+
Other ______________

Tribal, regional, or ancestral affiliations (if known): *

Do you need financial assistance or sliding scale pricing? *

Yes
No

Would you benefit from Buy Now, Pay Later (BNPL) options? *

Yes
No

Do you agree to be contacted for follow-up or legacy support? *

Yes
No

Would you like to opt into anonymous storytelling, testimonials, or events? *

Yes
No
Maybe Later

Anything Else You’d Like Us to Know? *