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Genetics Dog Submission Form

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Genetics Dog Submission Form + Invoice to owner to owner + Invoice Submission form Customer-No. / Barcode LABOR FÜR KLINISCHE DIAGNOSTIK GMBH & CO. KG Genetics Dog PB 1810 DE-97668 Bad Kissingen Tel +49 971 72020 Fax +49 971 68546 Business Hours: Mon - Fri: 9:00 - 18:00 h, Sat: 9:00 - 13:00 h E-Mail: [email protected] Clinic address: Invoice to: Owner: I agree to allow my data to be transmitted to and processed by (Stamp or block letters) (Block letters only, please) Laboklin gmbH & Co. KG in order to Veterinarian Name: _________________________________________fulfill this contract. Owner I have read the information and details on the use of the data and my rights at First name:_________________________________________http://laboklin.com/dataprotection. Date of _birth:________________________________________ (If the invoice should be sent to the owner or submitter, please_________________________________________ include their complete address and signature ) (Owners signature) Street: _________________________________________With my signature, I agree to pay the costs for the laboratory testing. VAT-No.: _________________________________________________ Zipcode/city:_________________________________________ Fax/email: _________________________________________________ _________________________________________ Fax/email:_________________________________________(Owners signature) Date/Signature:_______________________________________________________________ Tel.: _________________________________________ Courier Notification: Email Fax Mail Report copy to owner 8105 Certificate 9.00 € 1) The sample has to be collected by a veterinarian or authorized person. 2) The identity of the animal must be specified by Microchip-No., Tattoo-No. and/or Pedigree-No. 3) Certificates are included in the services of DNA profile and parentage testing; No certificates are provided for partner laboratory services. I have checked the animal(s) identity and confirm that the samples 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 - 1 ml EDTA-blood 2x buccal swab blood card 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 - 1 ml EDTA-blood 2x buccal swab blood card 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: __ __ __ __ - __ - __ __ __ __ __ ) Sample: 0.5 - 1 ml EDTA-blood 2x buccal swab blood card Sex: female male Name: _______________________________________________________________ Date of_ ______________________________________________birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.: Sample_______________________________________________ label: 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. 010110110087 Hereditary diseases € € 8552 Acatalasemia 59.50 8311 Epidermolytic hyperkeratosis (EHK) 59.50 (Beagle) (Norfolk Terrier) 8166 Achromatopsia (day blindness) (ACHM) 59.50 8202 Episodic falling (EF) 59.50 (German Shepherd, Labrador Retriever) (Cavalier King Charles Spaniel) 8595 Acute respiratory distress syndrome (ARDS) 59.50 8152 Exercise induced collapse (EIC) 77.50 (Dalmatian) (Boykin Spaniel, Chesapeake Bay Retriever, Clumber Spaniel, Curly Coated 8259 Adult onset neuropathy * ̓ ** (AON) 77.50 Retriever, Labrador Retriever, Old English Sheepdog, Pembroke Welsh Corgi, Wirehaired Pointer) (English Cocker Spaniel, Field Spaniel) 8038 Acral mutilation syndrome (AMS) 59.50 8151 Faktor VII deficiency 59.50 (English Cocker Spaniel, English Pointer, English Springer Spaniel, (Airedale Terrier, Alaskan Klee Kai, Beagle, Finnish Hound, Giant Schnauzer, French Spaniel, German Shorthaired Pointer) Scottish Deerhound, Welsh Springer Spaniel) 8313 Alaskan Husky encephalopathy (AHE) 59.50 8131 Familial nephropathy (FN)* 77.50 (Husky) (English Cocker Spaniel, Welsh Springer Spaniel) 8479 Alaskan Malamute polyneuropathy (AMPN) 59.50 8192 Familial nephropathy (FN) 59.50 (Alaskan Malamute) (English Springer Spaniel, Samoyed) 8601 Alexander disease (AxD) 59.50 8272 Fanconi syndrome 59.50 (Labrador Retriever) (Basenji) 8303 Amelogenesis imperfecta / Familial enamel 59.50 8467 Finnish Hound ataxia (FHA) 59.50 hypoplasia (AI/FEH) (Finnish Hound, Norrbottenspitz) 8016 (Italian Greyhound, Samoyed) Fucosidosis 59.50 8207 Bardet-Biedl syndrome (BBS) 59.50 (English Springer Spaniel) 8323 (Puli) Gallbladder mucoceles 59.50 8219 Brachyuria (stumpy tail) 59.50 (American Cocker Spaniel, Cairn Terrier, English Cocker Spaniel, Pomeranian, (Australian Shepherd, Australian Stumpy Tail Cattle Dog, Austrian Pinscher, Shetland Sheepdog) Bourbonnais Pointer, Bouvier des Ardennes, Brazilian Terrier, Brittany Spaniel, 8077 59.50 Croatian Sheepdog, Danish/Swedish Farmdog, Jack Russell Terrier, Karelian Glanzmann Thrombastenia (GT) Bear Dog, Mudi, Polish Lowland Sheepdog, Pyrenean Shepherd, Savoy (Pyrenean Mountain Dog) 8635 Sheepdog, Schipperke, Spanish Waterdog, Swedish Vallhund, Welsh Corgi) Glaucoma and goniodysgenesis (GG) 59.50 8184 C3-deficiency (C3) 59.50 (Border Collie) 8007 (Brittany Spaniel) Globoid cell leukodystrophy (Krabbe disease) 59.50 8012 Canine leukocyte adhesion deficiency (CLAD) 59.50 (Cairn Terrier, Irish Setter, West Highland White Terrier) 8322 (Irish Setter, Irish Red and White Setter) Glycogen storage disease GSD Ia 59.50 8330 Canine multi-focal retinopathy (CMR1/2/3) 77.50 (Maltese) 8513 e to owner + Invoice (American Bulldog, Australian Shepherd, Boerboel, Bullmastiff, Cane Corso, Glycogen storage disease GSD II (Pompe disease) 59.50 Coton de Tulear, Dogo Canario, Dogue de Bordeaux, English Bulldog, Finnish (Finnish Lapphund, Lapponian Herder, Swedish Lapphund) Lapphund, French Bulldog, Lapponian Herder, Mastiff, Pyrenean Mountain Dog, 8156 Swedish Lapphund) Glycogen storage disease GSD IIIa 59.50 8575 (Curly Coated Retriever) 59.50 8066 Canine multiple system degeneration (CMSD) GM1-Gangliosidosis (GM1) 59.50 (Chinese Crested, Kerry Blue Terrier) (Portuguese Waterdog, Shiba Inu, Siberian Husky) 8073 Centronuclear myopathy (CNM) 59.50 8208 GM2-Gangliosidosis (GM2) 59.50 (German Hunting Terrier, Great Dane, Labrador Retriever) (Japanese Chin, Shiba Inu, Toy Poodle) 8314 Cerebral dysfunction (CDFS) 59.50 8098 Grey Collie syndrome (GCS) 59.50 (Stabyhoun) (Canine cyclic neutropenia) 8316 Chondrodysplasia (dwarfism) 59.50 (Collie) 8232 (Chinook, Karelian Bear Dog, Norwegian Elkhound) Haemophilia A (factor VIII deficiency) 77.50 8326 Cleft lip/palate and syndactyly (CLPS) 59.50 (Boxer, German Shepherd, Havanese, Old English Sheepdog) 8221 (Nova Scotia Duck Tolling Retriever) Haemophilia B (factor IX deficiency) 77.50 8120 Collie eye anomaly (CEA) * ̓ ** Optigen 157.00 (Lhasa Apso, Rhodesian Ridgeback) 8319 8304 Collie eye anomaly (CEA) * partner laboratory 59.50 Haemorrhagic diathesis (Scott syndrome) 59.50 (Australian Shepherd, Bearded Collie, Border Collie, Boykin Spaniel, Hokkaido, (German Shepherd) 8449 Lancashire Heeler, Longhaired Wippet, Nova Scotia Duck Tolling Retriever, Hereditary ataxia (HA) 59.50 Rough/Smooth Collie, Shetland Sheepdog, Silken Windhound) (Gordon Setter, Old English Sheepdog) 8256 Cone degeneration (CD) * ̓ ** Optigen 167.00 8157 Hereditary cataract (HSF4) 59.50 (Alaskan Malamute, Australian Shepherd, German Shorthaired Pointer) (Australian Shepherd, Wäller) 8434 Congenital hypothyroidism with goiter (CHG) 59.50 8576 Hereditary cataract (HSF4)* 59.50 (Fox Terrier, French Bulldog, Rat Terrier, Spanish Waterdog, Tenterfield Terrier) (Boston Terrier, French Bulldog, Staffordshire Bull Terrier) 8317 Congenital ichthyosis 59.50 8269 Hereditary deafness (PTPRQ) 59.50 (Great Dane) (Dobermann) 8206 Congenital myasthenic syndrome (CMS) 59.50 8672 Hereditary nasal parakeratosis (HNPK) 59.50 (Golden Retriever, Jack Russell Terrier, Labrador Retriever, Old Danish (Greyhound) Pointing Dog, Parson Russell
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