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Order Form for Dog Genetic Testing

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Order Form for Dog Genetic Testing - Sample number (don‘t fill, if you don‘t know) Order form for dog genetic testing Name of the veterinary clinic Owner/Breeder (Do not fill in, if the customer is a breeder or an owner of the dog) Name: ..................................................................................................................................................................................................................................................................................... Street: ..................................................................................................................................................................................................................................................................................... Post code, town: ............................................................................................................................................................................................................................................. Country: ..................................................................................................................................................................................................................................................................................... VAT No.: .............................................................................................................................................................................................................. Tel.: ..................................................................................................................................................................................................................................................................................... E-mail: ................................................................................................................................................................................................................................ E-mail: ..................................................................................................................................................................................................................................................................................... Invoiced to: clinic breeder Send the test result report by: e-mail post + e-mail (+3,50 €) Payment: cash bank transfer card (PayPal service) (+3,50 €) DOG Sex: female male Sample type: swab blood other Name: ................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. Breed: ......................................................................................................................................................................................................................................................................................................................................................................... Date of birth: ....................................................................................................................................... Microchip: (usually 15 digits) Tattoo No.: ........................................................................................................................................................................................................................... Registration No.: ....................................................................................................................................................................................................................................... Dog coat color: (required for coat color testing) ............................................................................................................................................................................................................................................................................................................................................................................................................... Orders accepted on-line are free of charge. Extra charge (2 €) for order forms in paper. Why to make an on-line order? No extra charge (2 €), faster handling and no mistyping! Note: Kennel Club can apply specific rules for the sample collection. Samples collected without any identity verification by the authorized person might not be recognized by your Kennel Club. Hereby, I confirm that the animal identification (microchip / tattoo) complies with the facts stated above. I confirm, I have collected and labelled the sample(s).: Vet’s name and stamp: ......................................................................................................................................................... I hereby grant my approval to Genomia s.r.o. to be informed about their services in veterinary genetisc and allergology, discounts and sample collection events. For more information visit www.genomia.cz/en/terms_conditions Upon completing this order, I agree to Genomia‘s General Business Terms and Conditions and, at the same time, I give my informed consent to store and process my personal data. For more information visit www.genomia.cz/en/terms_conditions The biological sample sent together with this order form contains Category I animal by-products (EC No. 1069/2009). Genomia s.r.o. • Republikánská 6 • 312 00 Plzeň • Czech Republic • +420 373 749 999 • e-mail: [email protected] • www.genomia.cz REV 16/06/2020 - Sample number (don‘t fill, if you don‘t know) Tick the required tests: GR-PRA2 (Golden Retriever) GRMD (Golden Retriever) ADPRA (English Mastiff, Bullmastiff) GSDII (Lapphunds) AI (Akita, Italian Greyhound) GSD IIIa (Curly Coated Retriever) AMPn (Alaskan Malamute) HC (more breeds) AMS (more breeds) HN (English Springer Spaniel) ARDS (Dalmatian) Hyperuricosurie (more breeds) ARVC (German Boxer) ICT-A (Golden Retriever) Bas-PRA (Basenji) IGS (Beagle, Border Collie) BNAt (Coton de Tulear) IMGD (Great Danes) BSS * (English Cocker Spaniel) IPD (Rough Collies) BTPKD (English Bull Terrier) JLPP (Rottweiler, Black Russian Terrier) „Bully“ Whippet (Whippet) Juvenile Epilepsy (Lagotto Romagnolo) CaniLine - purebred test L-2-HGA (Staffordshire Bullterrier) CD (more breeds) LAD (Bull Terrier, Miniature Bull Terrier) CDPA / CDDY (IVDD) (more breeds) Lafora epilepsy (beagle, dachshund miniature wire-haired) CEA* (more breeds) LOA (Parson Russel and Jack Russel Terrier) CJM (Belgian Shepherds) LP (Miniature Bull Terriers, Bull Terriers) Chondrodysplasia (Karel. Bear Dog, Norw. Elkhound Grey) LSDs (Lagotto Romagnolo) CKCSID (Cavalier King Charles Spaniel) MAC (Schnauzer Miniature) CLAD (Irish setter) Malignant Hyperthermia (all breeds) CMO (WHWT, Cairn Terrier, Scottish Terrier) MDL (Landseer) CMR1 (more breeds) MDR1 (more breeds) CMR2 (Coton de Tulear) MLS (Beagle) CMSD (Chinese Crested, Kerry Blue Terrier) Myoclonic epilepsy (Rhodesian ridgeback) CNGA1-PRA (Shetland Sheepdog) NAD (Papillon) CNM (Labrador Retriever) NCCD (Beagle, Hungarian Vizsla) Comma defect (SCD) (Miniature Schnauzer) NCL-A (Amstaff, American Pit Bull Terrier) Congenital ichthyosis (American Bulldog) NCL5 (Australian Cattle Dog, Border Collie, Golden Retriever) Congenital Myotonia (Miniature Schnautzer) NCL6 (Australian Shepherd, Mini American Shepherd) Cord1-PRA (Engl. Spr. Spaniel, Miniature long-haired NCL8 (Alpine Dachsbracke, Saluki) Dachshund) NCL10 (American Bulldog) Cord2-PRA (Standard wire-haired Dachshund) NCL12 (Australian Cattle Dog) CSNB (Briard) NEWS (Standard Poodle) CT (Bedlington Terrier) OSD1 (Labrador Retriever) Cystinuria (Newfoundland, Landseer, English and French Osteogenesis imperfecta (Dachshund) Bulldog) Pap-PRA1 (Papillon) DCM (Schnauzer, Welsh springer spaniel) PCD (Alaskan Malamute, Old English Sheepdogs) DM* (more breeds) PDP1 (Clumber and Sussex Spaniel) DNA archiving PFK (Engl. Springer Spaniel, American Cocker Spaniel) DNA profile PH I (Coton de Tulear) Dog paternity - state the relationship: ....................................... PK deficiency (Labrador retriever, beagle, pug) Dwarfism (German Shepherd, Saarloos wolfdog, PLL (more breeds) Czechoslovakian shepherd) POAG (Beagle) Dwarfism SD2 (Labrador Retriever) POAG-PLL (Shar Pei) EIMM (German Hunting Terrier) Polyneuropathy (Greyhound) Factor VII deficiency (more breeds) PRA-prcd (more breeds) Fanconi syndrome (Basenji) PRA1 (HIVEP3, Miniature Schnauzer) FN (English Cocker Spaniel) PRA3 (Tibetan Terrier) Fucosidosa (English Springer Spaniel) PRA-rcd1 (Irish Setter) GLD (West Highland White and Cairn Terriers) PRA-rcd1a (Sloughi) GM1 (Portuguese water dog, Shiba Inu) PRA-rcd2 (Collies) GM2 (Shiba Inu) PRA-rcd3 (more breeds) Goniodysgenesis and glaukom (Border Collie) PRA-rcd4 (Gordon Setter, Irish Setter, Tibetan Terrier) GR-PRA1 (Golden Retriever) Raine syndrome (Border Collie) Additional requirements: ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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