Submission Form
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Submission Form Genetic tests for dogs D-45659 Recklinghausen Berghäuser Straße 295 (Please write legibly and in block letters) Phone: +49 [0] 2361 3000 121 Fax: +49 [0] 2361 3000 169 Membership breed club: YES ☐ NO ☐ E-mail: [email protected] (If YES - please attach a copy of your membership card) Internet: www.biofocus.de Sender/Owner Full name: __________________________________________ Country:_______________________________ Street:_____________________________________________ Phone:________________________________ City:______________________________________________ Fax:__________________________________ State:____________________ Zip-Code:_______________ E-mail:_______________________________ Date/Signature:______________________________________ Dog information Name: ___________________________________ Tattoo-No.: __________________________________ Breed: ___________________________________ Registration-No.: _____________________________ Coat color: ________________________________ Chip-No.: ___________________________________ (required for certificates) Date of birth: ______________________________ Gender: female ☐ male ☐ Dog’s parents: (only necessary for coat color and coat type tests) Dam’s name: ________________________________ Sire’s name: __________________________________ Breed: _____________________________________ Breed: ______________________________________ Coat color: _________________________________ Coat color: __________________________________ Coat length longhair ☐ shorthair ☐ Coat length longhair ☐ shorthair ☐ (only for coat length test) (only for coat length test) Sample specification Sampling by: ☐ Owner/Sender ☐ Independent authority (e.g. veterinarian or breed warden) Sample material: buccal swabs (2 samples) ☐ EDTA-blood (approx. 0.5 ml) ☐ Please perform the buccal swab thoroughly and make sure that the dog being tested has not eaten anything for at least 30 minutes. Further information about sample collection can be found on our homepage. Sample labeling: _________________________________________ Date of sampling: ________________________________________ I hereby confirm that the identity of the above-listed animal was verified and that the samples derive from the above-listed animal. __________________________________ stamp/signature independent authority Submission of results Test-results will be send to either the Owner/Sender and/or Veterinarian Test-results to: Owner/Sender ☐ Veterinarian ☐ Invoice to: Owner/Sender ☐ Veterinarian ☐ Certificate ☐ certificates will be provided for each test separately Certificate for the first test is free of charge, certificates for two to five tests will cost 7.14 €, more than five certificates will cost 14.28 € (incl. VAT). Certificates are available only if Chip-No. is provided. It is recommended that sampling is carried out by an independent authority (e.g. veterinarian or breed warden) to confirm sample origin. Certificate for DNA-profile will cost 7.14 € (incl. VAT), reports for parentage verification are free of charge. Sender/Owner: _____________________________________________ Dog’s name: ________________________________________________ Genetic Disorders Bandera's neonatal ataxia Musladin-Lueke syndrome (MLS) (Coton de Tulear) ☐ (Beagle) ☐ Brachyury / Tail, short Myopathy, centronuclear (Australian Shepherd, Austrian Pinscher, Australian Stumpy Tail Cattle Dog, ☐ (Labrador Retriever) ☐ Bourbonnais Pointer, Brazilian Terrier, Brittany Spaniel, Croatian Sheepdog, Danish-Swedish Farmdog, Jack Russell Terrier, Karelian Bear Dog, Mudi, Narcolepsy ☐ Polish Lowland Sheepdog, Pyrenean Shepherd, Savoy Sheepdog, Schipperke, (Dachshund, Dobermann, Labrador Retriever) Spanish Waterdog, Swedish Vallhund) Neonatal cerebellar cortical degeneration (NCCD) Chondrodysplasia (Beagle) ☐ (Basset Hound, Cairn Terrier, Cardigan Welsh Corgi, Dachshund, Dandie ☐ Neonatal encephalopathy with seizures (NEWS) Dinmont Terrier, Lancashire Heeler, Norwich Terrier, Pembroke Welsh (Poodle) ☐ Corgi, Petit Basset Griffon Vendeen, Skye Terrier, Swedish Valhund, Tebetian Spaniel, West Highland White Terrier) Nephropathy (English Cocker Spaniel) ☐ Copper toxicosis / Wilson disease (Bedlington Terrier ) ☐ Neuroaxonal dystrophy, PLA2G6-related (Papillon) ☐ Cystinuria, type I - A Neuronal ceroid lipofuscinosis (NCL) (Newfoundland, Landseer) ☐ (American Bulldog, American Staffordshire Terrier, Australian Cattle Dog, ☐ Cystinuria, type III ☐ Australien Sheperd, Border Collie, Chinese Crested, Chihuahua, English SLC3A1 and SLC7A9 mutations Setter, Long-haired Dachshund, Tibet Terrier) (American Bulldog, English Bulldog, Continental Bulldog, French Bulldog, Leavitt Bulldog, Old English Bulldog) Neutropenia, cyclic / Grey Collie Syndrom (Collie) ☐ Degenerative myelopathy (DM Combi-Test)) ☐ SOD1:c.118G>A mutation / SOD1: c.166+9_c.166+10ins Oculoskeletal dysplasia 2 (OSD2/DRD2) ☐ (Hovawart, Collie (Rough), Poodle ) (Samoyed) Degenerative myelopathy (DM)* Osteogenesis imperfecta SOD1:c.118G>A mutation ☐ (Dachshund) ☐ (all breeds) Phosphofructokinase deficiency (PFK) / ☐ Dry Eye Curly Coat + Episodic Falling (Combi) ☐ Glycogen Storage Disease VII (GSD VII) (Cavalier King Charles Spaniel) (American Cocker Spaniel, English Springer Spaniel, Whippet, English Cocker Dry Eye Curly Coat Syndrom Spaniel, Wachtelhund) (Cavalier King Charles Spaniel) ☐ Primary ciliary dyskinesia (PCD) (Bobtail (Old English Sheepdog)) ☐ Duchenne muscular dystrophy (DMD) ☐ (Cavalier King Charles Spaniel) Primary hyperoxaluria type I (PH1) ☐ Episodic falling (Coton de Tulear ) (Cavalier King Charles Spaniel) ☐ Pug Dog Enzephalitis (PDE) / Factor VII deficiency Necrotizing meningoencephalitis (NME) ☐ (Airedale Terrier, Alaskan Klee Kai, Beagle, Giant Schnauzer, Scottish ☐ (Pug) Deerhound) Pyruvate dehydrogenase deficiency Fucosidosis, alpha (Clumber-Spaniel, Sussex-Spaniel) ☐ (English Springer Spaniel ) ☐ Pyruvate kinase deficiency ☐ GM1-Gangliosidosis ☐ (Basenji, Cairn Terrier, Westhighland White Terrier) (Husky) Severe combined immunodeficiency disease (SCID) ☐ Golden Retriever Muscular dystrophy (GRMD) ☐ autosomal (Golden Retriever) (Jack Russell Terrier) Haemophilia A / Factor VIII deficiency ☐ Severe combined immunodeficiency disease (XSCID) X-linked X-linked ☐ (Havanese) (Basset Hound, Welsh Corgi) Hyperkeratosis, palmoplantar ☐ Trapped Neutrophil Syndrome (TNS) (Irish Terrier, Kromfohrländer) (Border Collie) ☐ Hyperuricosuria Von Willebrand disease I (vWD) (all breeds) ☐ (Australian Labradoodle, Basset Hound, Bernese Mountain Dog, Coton de ☐ Ichthyosis Tulear, Miniature Long-Haired Dachshund, Miniature Smooth-Haired Dachshund, Long-Haired Dachshund, Smooth-Haired Dachshund, German (Golden Retriever) ☐ Shepherd Dog, Dobermann, Drentse Patrijshond, Stabijhoun, Golden Krabbe disease Retriever, Goldendoodle, Poodle, Kerry Blue Terrier, Kromfohrländer, (Cairn Terrier, Irish Setter, Westhighland White Terrier) ☐ Manchester Terrier, Miniatur Wire-Haired Dachshund, Papillon, Poodle Leukocyte adhesion deficiency, type I (CLAD) Multicolor, Poodle Toy, Rabbit Dachshund Long-Haired, Rabbit Dachshund Smooth-haired, Rabbit Wire-Haired Dachshund, Rottweiler, Standard Wire- (Irish Setter, Irish Red and White Setter) ☐ Haired Dachshund, Welsh Corgi (Pembroke), Wolfsspitz, Miniature Poodle, Malignant hyperthermia Miniature Schnauzer) ☐ (all breeds) Von Willebrand disease II (vWD) Mucopolysaccharidosis VII (MPS VII) (German Shorthaired Pointer, German Wirehaired Pointer) ☐ ☐ (German Shepherd Dog) Von Willebrand disease III (vWD) Multidrug resistance 1 (MDR1) (Scottish Terrier, Shetland Sheepdog) ☐ (Australian Shepherd, Bobtail (Old English Sheepdog), Border Collie, Collie ☐ *partner laboratory (Rough), Collie (Smooth), Longhaired Whippet, Shetland Sheepdog, Silken Windhound, Wäller, White Swiss Shepherd Dog, Toy Australian Shepherd, German Shepherd Dog) Muscular hypertrophy (bully whippet) (Whippet) ☐ Sender/Owner: _____________________________________________ Dog’s name: ________________________________________________ Eye Disorders Achromatopsia (cone degeneration, hemeralopia), GSPT Rod-cone dysplasia 1 (German Shorthair Pointer) ☐ (Irish Setter, Irish Red and White Setter) ☐ Autosomal dominant progressive retinal atrophy (ADPRA) Rod-cone dysplasia 1a (English Mastiff, Bull Mastiff) ☐ (Sloughi) ☐ Collie eye anomaly (CEA) Rod-cone dysplasia 4 (rcd4) (Australian Shepherd, Border Collie, Boykin Spaniel, Lancashire heeler, ☐ (Gordon Setter, Irish Setter) ☐ Longhaired whippet, Collie (Rough), Shetland Sheepdog, Silken Windhound, **all test results will be reported to the International Schapendoes Federation Collie (Smooth)) Cone rod dystrophy 1 (crd1) (American Staffordshire Terrier) ☐ Cone rod dystrophy 2 (crd2) (American Pitt Bull Terrier) ☐ Coat Colors A-Locus: ay, aw, at, a-alleles Cone rod dystrophy 3 (crd3) ☐ (Glen of Imaal Terrier) ☐ Sable-fawn, wild type, wolf sable, black-and-tan, saddle-tan, recessive black Cord1 - Cone rod dystrophy 4 (crd4) (all breeds) (Miniature Long-Haired Dachshund, Miniature Smooth-Haired Dachshund) ☐ B-Locus: Crd - Cone rod dystrophy ☐ ☐ Brown, chocolate (Miniature Wire-Haired Dachshund, Wire-Haired Dachshund) (all breeds) Generalized progressive retinal atrophy (gPRA)** ☐ D-Locus: (Schapendoes) Dilution ☐ Golden Retriever PRA 1 (GR-PRA1) (all breeds) (Golden Retriever) ☐ E-Locus: EM-allele Golden Retriever PRA 2 (GR-PRA2) Melanistic mask ☐ (Golden Retriever) ☐ (all breeds) Leber congenital amaurosis / E-Locus: ☐ Congenital stationary night blindness ☐ Yellow, lemon, red, cream, apricot (Briard) (all