KRAS-variant Order Form CLIA-CERTIFIED LAB Step 1 of 11 9% Name* First Last Email* Your Email Please Confirm Your Email Would you like:* To know my KRAS-variant Results and to submit my DNA for research studies, $129 To know my KRAS-variant Results, $159 To receive a test kit to send in my sample for research studies only, $0 To know my KRAS-variant Results and to submit my DNA for research studies, and I was in the Army of Women Study OR I need financial assistance Please note: Test kit shipping and handling is $15.Common Questions Why would I submit my DNA for research? By joining a MiraKind study, you can play a role in helping MiraKind answer some of the most pressing questions associated with risk of disease in individuals. We are on a mission to better understand the behaviors, environmental factors, and lifestyle choices that can influence an individual’s risk of cancer, and your participation in a study helps us get closer to finding the answers to improve health for all individuals with the KRAS-variant, as well as to understand new mutations like the KRAS-variant. What do I need to know if submit my sample to a study? To participate in our research studies, you'll need to complete a survey that takes about 15 minutes, if you have not yet. You'll also need to read the consent in this form and agree. We may contact you in the future with follow-up questions. Do you need financial assistance? Please contact Dr. Joanne Weidhaas here. Reason(s) for testing, check all that apply:* Personal history of cancer Family history of cancer Personal or family history of more than one cancer in an individual (multiple primary cancer) To help guide the decision regarding hormone replacement therapy Current cancer diagnosis for information to help guide the decision on treatment choice IMPORTANT NOTE: If you received an email from MiraKind about sending in your sample the answer to the next question is YES.Have you already taken a survey to participate in a study and need a kit to send your sample in?* Yes No Before you order, please note that a physician must deliver your test results. You have the option of using your own or you may select one of our partners that can connect you with a physician. If you choose to use your own, be sure to have your physician's phone number and address ready. Our partner, Gennev, has OB/GYNs that charge $85 for 20 minutes to discuss your results and to answer any questions you may have. IMPORTANT: After submitting your information, you will need to complete a 15 minute survey so we have the information and permission we need for using your sample in our studies. Completion of the survey is required. Phone Number* Your current SHIPPING Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Your Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Physician (Note: A physician must be involved in the reporting of this test. If you need one a physician, please select one of our partners)* I need to request a physician through your partner, Gennev, and I understand there is a $85 fee to receive and discuss my results with an OB/GYN I have a physician I'd like to release my results to both Gennev and my physician Your Physician's Name* First Last Your Physician's Phone Number* Your Physician's Fax Number Your Physician's Email Address Your Physician's Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I understand the benefits and limitations of the testing to be performed as indicated. I understand that a positive test result serves only as a predictor of risk or response. I understand that a negative test results does not assure no risk or response. I understand a physician must deliver my results to me. I consent to being tested for the KRAS-variant. I understand the benefits and limitations of the testing to be performed as indicated. I understand that a positive test result serves only as a predictor of risk or response. I understand that a negative test results does not assure no risk or response. I understand a physician must deliver my results to me. I consent to being tested for the KRAS-variant. I consent for my genetic sample to be used in MiraKind research studies. I understand my personal information will never be shared. I consent for my genetic sample to be used in any MiraKind research studies. I understand my personal information will never be shared. Click here to review the consent document. I have read this form and decided that I will participate in the study described above. Its general purposes, the particulars of involvement and possible hazards and inconveniences have been explained to my satisfaction. I understand I will be emailed a PDF copy of the consent document. I agree that I have read and accept the above terms* I agree I acknowledge I am responsible for $159 when I submit this form. I understand my individual results and information will never be shared without my permission. I do give MiraKind consent to release my results to my chosen physician.* I agree I acknowledge I am responsible for $129 when I submit this form. I understand my individual results and information will never be shared without my permission. I do give MiraKind consent to release my results to my chosen physician.* I agree MiraKind is an independent nonprofit that runs studies to answer questions about cancer for individuals and their families with novel germline mutations. I would like to be signed up for the MiraKind newsletter to keep up to date on studies and results from studies.* Yes, please subscribe me No thanks KRAS-variant Test Price: KRAS-variant Test with Study Submission Price: Shipping for Test Kit KRAS-Variant Test Please enter in the amount you can pay at this time. $15 minimum.Total $0.00 Credit Card*Card Details Cardholder Name Almost done! Please click "Send" only ONE TIME to complete your order. Give the system a minute or so to process your order and then you will be redirected to a success page. Thank you!