Client S Details

CLIENT’S DETAILS:

Client’s name:______

Address:______

______

__ Postal code: ______

Tel/Cell: ______E-mail:

______

ACCOUNT FOR:

Name: ______VAT No.: ______

Address:______

______

__ Postal code: ______

1 Tel/Cell: ______E-mail:

______

PAYMENT AND RESULTS:

Preferred method of receiving results: Fax  E-mail 

Post

E-mail to be sent to:

______

Method of payment: Cash Electronic transfer 

* Please note results will only be issued once payment is received ANIMAL’S DETAILS: Dog’s name: ______Microchip No.: ______Registration No.: ______Breed: ______Colour: ______Sex: M  F  Date of birth: YYYY/MM/DD

GENETIC HEALTH TEST REQUIRED:

Fucosidosis Heritable cataracts (HC) (English Springer Spaniels) (Staffordshire Bull Terrier, Boston Terrier, Familiar Nephropathy (FN) Australian Shepherd) (Cocker Spaniel) von Willebrand’s Disease Type I Phosphofructokinase (PFK) (Dobermann, Bernese Mountain Dog, Kerry (English Springer Spaniels) Blue Terrier, Pembroke Welsh Corgi, Poodle) Ceroid Lipofuscinosis (CL) von Willebrand’s Disease Type III (Border collie) (Shetland Sheepdogs and Scottish Terriers) L2-Hydroxyglutaric Aciduria (L2HGA) Primary Lens Luxation (PLL) (Staffordshire Bull Terrier) (Chinese crested, Jack Russell terrier, Mini bull Cystinuria terrier, Australian cattle dog) (Newfoundland and Labrador retrievers) Canine Leukocyte Adhesion Deficiency (CLAD) Exercise Induced Collapse (EIC) (Irish Setters and Irish Red-and-White Setters) (Labrador Retrievers) Multiple drug resistance (MDR1) Progressive Retinal Atrophy (prcd) (Australian Shepherd, Border Collie, English (Labrador Retriever, Golden Retriever, Shepherd, German Shepherd Dog, Old English Miniature and Toy Poodle, English and Sheepdog, Rough and Smooth Collie, Shetland American Cocker Spaniel, Australian Cattle Sheepdog) Dog, Australian Shepherd, Chinese Crested, Degenerative Myelopathy (DM) Yorkshire Terrier) Progressive Retinal Atrophy (crd1) (Various breeds including Boxers, German (Miniature Smooth and Longhaired shepherd dogs, Rhodesian Ridgebacks and Dachshund; English Springer Spaniels) Corgis) Progressive Retinal Atrophy (rcd1) Collie Eye Anomaly (CEA) (Irish Setters and Irish Red-and-White Setters) (Australian Shepherd, Border Collie, Rough and Progressive Retinal Atrophy (rcd3) Smooth Collie, Shetland Sheepdog) (Cardigan and Welsh Corgi breeds) Imerslund-Gräsbeck Syndrome (IGS) Late onset Spinocerebellar Ataxia (LOA) (Border Collie) (Jack Russel Terrier and Parson Russel) Trapped Neutrophil Syndrome (TNS) Spinocerebellar Ataxia (SCA) (Border Collie) (Jack Russel Terrier and Parson Russel)

OTHER: ______

COLOUR TEST REQUIRED:

Colour inheritance (please select) B Locus (Chocolate/Liver) D Locus (Dilution/Blue) E Locus (Gold)

PROFILE/PARENTAGE TESTING:

Canine’s Name Microchip No. Registration No. Relationship (i.e. Puppy, Bitch, Sire)

SAMPLE DECLARATION: I confirm that the sample enclosed was obtained from the dog described above.

Name and signature of person taking the sample:

______

Name and signature of client:

______

Sample label: ______Date samples were collected:

YYYY/MM/DD

Sample type: 1 – 2 ml Whole Blood in EDTA tube  FTA card 

KUSA HEALTH CERTIFICATE DATABASE:

KUSA requires all test results of dogs registered to be included into their Health Certificate Database. Inqaba biotec requires the owner’s consent before issuing the data.

I hereby give my permission that inqaba biotec may send the tests results to KUSA to form part of the KUSA Health Certificate Database Yes No