ORDER FORM - GENETIC TESTING DOG / CAT
VETERINARY CLINIC OWNER / BREEDER Vet: Name: Clinic: Street: Street: City: City: Post code: Post code: Country: Country: E-mail (mandatory): E-mail: Phone: Phone:
Payment method: bank transfer PayPal / credit card Invoice to: clinic owner Owner’s signature:
ANIMAL DATA Sample number (do not fill, for laboratory use only)
Species: dog cat
Sex: male female Sample collection date:
Sample type: blood buccal swab other: Name:
Breed:
Date of birth:
Chip number:
Pedigree number:
Tatoo number:
IDENTITY CONFORMATION (NON-COMPULSORY)
NOTE: Some breeding organizations require conformation of animal identity by veterinarian or other independent person when taking samples. Samples without identity conformation might not be recognized by local breeding organization.
I declare that I checked animal identity and confirmed that the sample is from animal specified on this order form.
VET‘S SIGNITURE & STAMP:
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EVG d.o.o. - Taborska ul. 8 - 2000 Maribor - Slovenija - Tel. +38640566273 - E-mail: [email protected] - web: www.eurovetgene.com
1 GENETIC DISEASES - DOG AD - PRA (English Mastiff, Bullmastiff) GRMD (Golden Retriever)
AI/FEH (Parson Russ. Ter., Akita, Ital. Greyhound, Samoyed) GSDII (Finnish, Swedish Lapphund, Lapponian Herder)
AMPN (Alaskan Malamute) GSDIIIa (Curly Coated Retriever)
AMS (several breeds) HEREDITARY CATARACT - HSF4 (several breeds)
BAS - PRA (Basenji) HN (Samoyed)
BNAT (Coton de Tulear) HNPK* (Labrador Retriever)
CDPA/CDDY – IVDD (all breeds) HUU (all breeds)
CEA (several breeds) ICT - A (Golden retriever)
CHG (Toy Fox Terrier, Rat Terrier) ICT (American Bulldog)
CJM (Belgian Shepherd Dog) IGS (Border Collie, Beagle)
CKCSID (Cavalier King Charles Spaniel) IMGD (Great Dane)
CLAD (Irish Setter) IPD (Collie)
CMO (West Highland White, Scottish and Cairn Terrier) JLPP (Black Russian Terrier, Rotweiller)
CMR1 (several breeds) JME (Rhodesian Ridgeback)
CMR2 (Coton de Tulear) JUVENILE EPILEPSY (Lagotto Romagnolo)
CMS (Labrador retriever, Danish Pointing Dog) L-2-HGA (Staffordshire Bull Terrier)
CMSD (Chinese Crested dog, Kerry Blue Terrier) LAD (Bullterier)
CMT - CHARCOT-MARIE-TOOTH (Miniature Schnauzer) LOA (Jack Russell Terrier, Parson Russell Terrier)
CNGA1- PRA (Shetland Sheepdog) LSD (Lagotto Romagnolo)
CNM (Labrador Retriever) MC (Miniature Schnauzer)
COMMA DEFECT (Miniature Schnauzer) MCD (Labrador retriever, Labradoodle)
CORD1 - PRA (several breeds) MD (Cavalier King Charles Spaniel, Landseer)
CORD2 - PRA (Standard wire-haired dachshund) MDR1 (several breeds)
CRD1- PRA (American Staffordshire, Am. Pit Bull Terrier) MH (all breeds)
CSNB (Briard) MLS (Beagle)
CYSTINURIA TYPE I (Newfoundland and Landseer) MPS VII (Brazilian Terrier)
CYSTINURIA TYPE IIB (Miniature Pinscher) MYOSTATIN DEFICIENCY - BULLY (Whippet)
CYSTINURIA TYPE III (Bulldog, French bulldog, Mastif) NAD (Spanish Water Dog, Papillon)
DCM (Doberman Pinscher, Schnauzer) NARCOLEPSY (Labrador Retriever, Doberman Pinscher)
DM* (all breeds) NCCD (Beagle)
DMS (Shetland Sheepdog, Collie) NCL 1 (Dachshund)
ED/SFS (Chesapeake Bay Retriever) NCL 10 (American Bulldog)
EF* (Cavalier King Charles Spaniel) NCL 2 (Dachshund)
EIC (several breeds) NCL 4A / Cerebellar Ataxia (several breeds)
FACTOR VII DEFICIENCY (several breeds) NCL 5 (Border Collie)
FANCONI SYNDROME (Basenji) NCL 6 (Australian Shepherd)
FN (English Cocker Spaniel, English Springer Spaniel) NCL 8 (English Setter, Irish Setter, Gordon Setter)
FUCOSIDOSIS (English Springer Spaniel) NCL A (Tibetan Terrier)
HEREDITARY DEAFNESS (Doberman Pinscher) NCL GR (Golden Retriever)
GCS (Rough Collie, Smooth Collie) NE (Standard Poodle)
GG (Border Collie) OI (Dachshund, Golden Retriever)
GLD (West Highland White Terrier, Cairn Terrier, Irish Setter) P2Y12 (Greater Swiss Mountain Dog)
GM1 (Portugese Waterdog, Siberian Husky, Shiba inu) PAP - PRA1 (Papillon)
GM2 (Toy Poodle, Shiba Inu) PCD (Bobtail)
GR - PRA1 (Golden Retriever) PDP1 (Clumber spaniel,Sussex spaniel)
GR - PRA2 (Golden Retriever) PFKD (several breeds)
2 GENETIC DISEASES - DOG DNA TEST PACKAGES - DOG
PH I (Coton de Tulear) Package - Border Collie (CEA, IGS, MDR1, SN, NCL, TNS, RAINE, GG)
PITUITARY DWARFISM (several breeds) Package - Austral. Shep. (CEA, DM*, HSF4, MDR1, BOB TAIL, NCL6, PRCD, CMR1)
PK (Beagle, Labrador retriever, Pug) Package - Labrad. Ret. 1 (EIC, PRCD, HNPK*, NARCO., CNM, SD2, RD/OSD)
PKD (Bull Terrier) Package - Labrador Retriever 2 (EIC, PRCD, HNPK*)
PLL (several breeds) Package - Golden Ret. 1 (PRCD, GR-PRA1, GR-PRA2, ICT-A, GRMD, NCL, OI)
PLN (Soft Coated Wheaten Terrier) Package - Golden Retriever 2 (PRCD, GR-PRA1, GR-PRA2)
POAG (Beagle) Package - Beagle (IGS, MLS, FVII, PK, NCCD, POAG)
POAG/PLL (Shar-Pei) Package - Jack / Parson Russel Terrier (LOA, SCA, PLL)
Polyneuropathy (Greyhound) Package - Lagotto Romagnollo (JE, LSD, FURNISHING)
PRA B1 (Miniature Schnauzer) Package - Poodle (DM*, RCD4, NE, PRCD, vWD1)
PRA - PRCD (several breeds) Package - Cavalier King Charles Spaniel (EFS*, CKCSID)
PRA - RCD1 (Irish Setter) Package - Collie (CEA, DM*, GCS, MDR1, RCD2, HUU, IPD)
PRA - RCD1a (Sloughi) Package - Long-haired Whippet (CEA, MDR, DM*)
PRA - RCD2 (Rough Collie, Smooth Collie) Package - Papillon (NAD, PAP-PRA1, vWD1)
PRA - RCD3 (several breeds) Package - Sheltie (CEA, MDR1, DM*, CNGA1-PRA, vWD3)
PRA - RCD4 (several breeds) Package - Sheltie XL (CEA, MDR1, DM*, CNGA1-PRA, vWD3, DMS)
RAINE SYNDROME (Border Collie) Package - Coton de Tulear (CMR2, BNAt, PH1, vWD1, PRCD, CDPA/CDDY)
RCND (German Shepherd Dog) Package - Stafordshire Bulterier (HSF4, L2HGA)
RD/OSD (Labrador retriever) Package - English Cocker Spaniel (FN, PRCD, AMS)
SCA (Jack Russell Terrier, Parson Russell Terrier) Package - English Spring. Spaniel (CORD1, FUCOSID., PFKD, FN, AMS)
SD2 – Dwarfism (Labrador retriever) Package - Tibetan Terrier (NCL, RCD4, PLL)
SDCA1 (Belgian Shepherd) Package - Landseer (CYSTINURIA, MD, DM*, D LOCUS)
SDCA2 (Belgian Shepherd) Package - French Buldog (HSF4, CMR1, DM*, HUU, CYSTINURIA TYPE 3)
SN (Border Collie) Package - Chin. Crested (CMSD, PRA-PRCD, PRA-RCD3, PLL, vWD2, DM*)
SPAID (Shar Pei) Package - Czechoslovakian Wolfdog (PIT. DWARFISM, DM*, FGF5)
TNS (Border Collie) Package - Austral. Cattle Dog (PRA-PRCD, PRA-RCD4, PLL, NCL5, DM*)
VDEGS (Wire Fox Terrier) Package - Giant Schnauzer (DCM, PRA-PRCD, FVII)
vWDI (several breeds) Package - Spanish Water Dog (PRCD, NAD, DM*, BOB TAIL)
vWDII (several breeds) Package – German Shepherd Dog (DM*, MDR1, HUU, FGF5, PIT. DW.)
vWDIII (Scotch Terrier, Shetland Sheepdog, Dutch Koiker) Package – Dachshund (CDPA/CDDY, CORD1, CORD2 , NCL1, NCL2, OI)
XL - PRA (Siberian Husky, Samoyed) Package – Doberman (DM*, DCM, VWD1, B LOCUS, D LOCUS, HER. DEAF.)
COAT COLOUR AND QUALITY - DOG Package – Irish Setter (CLAD, HUU, NCL8, RCD4, RCD1, VWD1)
E-Locus Package – Mastiff (CMR1, DM*, AD-PRA, HUU, CYSTINURIA TYPE 3)
B-Locus Package – Miniature Bull Terrier (HUU, LAD, PKD, PLL)
D-Locus Package – Old English Sheepdog - Bobtail (DM*, EIC, MDR, PCD)
K-Locus Package – Rhodesian Ridgeback (DM*, JME, B LOCUS, D LOCUS)
A-Locus Package – Rottweiler (DM*, JLPP, FGF5)
M-Locus (Merle) Package – Shiba Inu (GM1, GM2, A LOCUS, E LOCUS)
EM-Locus Package – Welsh Corgi (VWD1, DM*, CDPA/CCDY, BOB TAIL, RCD3)
S-Locus Package – Whippet (FIIV, MYOSTATIN DEFICIENCY, PFKD)
I-Locus Package – Portuguese Water Dog (PRCD, IMPROPER COAT, GM1)
Furnishing / improper coat (RSPO2) Package – Bull Terrier (LAD, PKD1, HUU)
Short tail – bobtail Package – Basenji (BAS-PRA, FANCONI)
Coat Length (FGF5) Package - Coat color (LOCUS: A, B, D, E, K, S) DNA PROFILE / PARENTAGE - DOG DNA profile (ISAG) * Partner lab
3 GENETIC DISEASES - CAT
PKD (Persian and related breeds)
HCM (Maine Coon, Ragdoll)
4