Submission form Customer-No. / Barcode LABOR FÜR KLINISCHE DIAGNOSTIK GMBH & CO. KG Genetics PB 1810 DE-97668 Bad Kissingen Tel +49 971 72020 Fax +49 971 68546 E-Mail: [email protected] Business Hours: Mon - Fri: 9:00 - 18:00 h, Sat: 9:00 - 13:00 h

Clinic address: Owners address: Send invoice to: (stamp or block letters) (block letters only, please) Veterinarian Name: ______Owner

First name:______

Date______of birth: ______(If the invoice should be sent to the owner or submitter, please (Owner/submitter) include their complete address and signature) Street: ______Vat/ID: ______Please note: Zipcode/city: Address for invoicing and ______signee must be identical Fax/e-mail: ______Fax/e-mail:______Date/Signature:______Courier Tel.: ______Notification: Email Fax Mail Report copy to owner

8105 Certificate 71,00 SEK

For certificates: 1) The sample has to be collected by a veterinarian or an authorized person. 2) The identity of the animal must be specified by Microchip-No., Tattoo-No., Registration-No. and/or Pedigree-No.. 3) Certificates are not issued for partner lab services.

I have checked the animal(s) identity and confirm that the submitted sample(s) are taken from the animal(s) listed below.

Name veterinarian: ______Signature / stamp veterinarian:______

Patient-ID: ______Date of sampling: ______

Please note: Indication of breed is mandatory! (Please complete using capital letters)

Animal 1 (previous result-number, if known: ______- __ - ______)

Sample: 0,5 ml EDTA-blood Hair Sex: female male

Name: ______Date of birth:______

Breed: ______Coat colour:______

Pedigree-No.: ______Tattoo-No.:______

Microchip-No.: Sample label:______

Animal 2 (previous result-number, if known: ______- __ - ______)

Sample: 0,5 ml EDTA-blood Hair Sex: female male

Name: ______Date of birth:______

Breed: ______Coat colour:______

Pedigree-No.: ______Tattoo-No.:______

Microchip-No.: Sample label:______

Animal 3 (previous result-number, if known: ______- __ - ______)

Probe: 0,5 ml EDTA-blood Hair Sex: female male

Name: ______Date of birth:______

Breed: ______Coat colour:______

Pedigree-No.: ______Tattoo-No.:______

Microchip-No.: Sample label:______

010130080036 Hereditary Diseases SEK SEK

8248 8501 AIS Hydrocephalus (Androgen insensitivity syndrome) (Quarter Horse) (Friesian Horse) 8214 8464 CA HWSD (Cerebellar abiotrophy) (Arabian) (Hoof Wall Separation Disease) (Connemara Pony) 8482 8000 Congenital Myotonia HYPP (New Forest Pony) (Hyperkalaemic Periodic Paralysis) (Quarter Horse) 8553 8231 Dwarfism LFS (Friesian Horse) (Lavender Foal Syndrom) (Arabian) 8160 8061 EMH OLWS (Equine Malignant Hyperthermia) (all breeds) (Lethal White Foal Syndrome) (all breeds) 8454 8138 FIS PSSM (Foal Immunodeficiency Syndrome) (Fell Pony, Dales Pony) (Polysaccharid-Storage-Myopathy Type I) (All breeds) 8137 8039 GBED SCID (Glycogen Branching Enzyme Deficiency) (Quarter Horse, Paint Horse) (Severe Combined Immunodeficiency) (Arabian) 8072 8470 H-JEB WFFS (Junctional Epidermolysis Bullosa) (Belgian ) ( Fragile Foal Syndrom) (Warmblood) 8139 HERDA (Hereditary Equine Regional Dermal Asthenia) (Quarter Horse, Paint Horse)

Test combinations 8267 8252 5-Panel-Test Combination Arabian (PSSM, GBED, HERDA, HYPP, EMH) (CA, LFS, SCID) 8250 8253 Combination Quarter Horse / Combination Warmblood (PSSM, GBED, HERDA, HYPP) (PSSM, WFFS) 8251 8372 Combination Paint Horse Combination Quarab (PSSM, GBED, HERDA, HYPP, OLWS) (CA, GBED, HERDA, PSSM, SCID)

Coat colours

8070 8159 Agouti Graying*

8140 8586 Appaloosa Pattern1 Incontinentia pigmenti (Hyperpigmentation)

8603 8433 Brindle 1

8463 8183 Camarillo White - W4* Pearl*

8174 8228 Champagne Roan Zygosity* (breeds upon request) 8048 8148 Chestnut Sabino-1

8071 8213 Cream Silver dapple

8227 8417 Dun Splashed White

8422 8130 GQ Santana Dominant White W10*

If more than one characteristic is requested we charge SEK 333,00 for the first and SEK 140,00 for each additional test (except partnerlabs). Performance

8187 Speed-Gen* DNA-Profiling According to ISAG 2006

8507 DNA-Profile (proof of identity, genetic fingerprint)

8109 Parentage verification (paternity test) each parent each offspring

A DNA profile from each partent is required for analyses of parentage. Please contact the lab prior to submission if only one parent is available for testing.

* Partnerlab

In order to allow breeding club discount for the owner please enclose a breeding club membership confirmation with each sample submission. The invoice cannot be altered subsequently.

Supply orders for veterinarians: Submission forms:

1 6 14 100 160 Serum tubes Swabs with transp.medium Histology containers with Allergy Hygiene 2 6a 110 150 Cltrate tubes Swabs without transp.med. formalin General Farm Animal 3 6b 5 170 120 EDTA tubes Container for swabs Feacal containers Genetics Dog Pathology 3a 12 7 190 130 Heparin tubes Cover for slides Urine containers Genetics Cat Equine 4 11 1B 180 140 NaFI tubes Container for tubes Eppendorf tubes Genetics Equine Reptiles 10 80 23 210 Envelopes large Barcodes Packing boxes Birds and Small Mammals General terms and conditions: Prices in SEK ex. VAT (19%) / Charge is x1,4 if invoice is sent to owner with an additional fee of SEK 41,00 for postage and packing / Services offered and prices may be subject to change / Samples and anonymised test results can be used for scientific purpose / Please find our complete general terms and conditions of business on www.laboklin.com S - 013008036 / 1707