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PCR REQUEST FORM - GENETIC DISEASE in Order to Enable Us to Process Your Sample(S) Efficiently, Please Complete All Information on This Form Using Black Ink

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IDEXX Reference Laboratories PCR REQUEST FORM - GENETIC DISEASE In order to enable us to process your sample(s) efficiently, please complete all information on this form using black ink. To help us process your sample as efficiently as possible, please provide all owner and PATIENT‘S NAME patient information including Kennel Club Registration Number and Microchip number. Please note the expected time for results is up to 8 weeks from receipt of the sample and completed form. KENNEL CLUB NAME DATE REGISTERED SPECIES VETERINARY SURGEON LAB NUMBER DATE OF BIRTH KENNEL CLUB No (LAB USE ONLY) ADDRESS STAMP SEX NEUTERED MICROCHIP No MR / MRS / MISS VET CODE OWNER‘S ADDRESS* POSTCODE MANDATORY INFO Does the animal originate from a country outside the UK (please state country) Y o N o Where: Has the animal recently travelled abroad or been in contact with a non-UK bred animal that has travelled abroad Y o N o Please indicate if the sample has been obtained from a patient receiving chemotherapy or radioactive iodine Y o N o See current Directory of Products and Services and www.vetconnect.co.uk for profile content & sample requirements For a full list of all available test, sample requirements and online ordering please visit www.vetconnectplus.co.uk FELINE GD26 Polycystic Kidney Disease (PKD) GD39 Degenerative Myopathy/ GD46 Trapped Neutrophil Syndrome GD16 Hypertrophic Cardiomyopathy American Shorthair, British Shorthair and degenerative radiculomyelopathy (TNS) Longhair, European Shorthair, Exotic (HCM) All Dog Breeds, American Eskimo, Border Collie Shorthair, Kartäuser, Himalaya Cat, Persian Chesapeake Bay Retriever, German Mutation A31P Maine Coon and their GD49 Hereditary Cataract Cat, Siam Cat, Ragdoll, Selkirk Rex, Shepherd, Golden Retriever, Labrador 2012018-0421-UK cross species, Mutation A74T Maine Australian Shepherd, Miniature American Scottish Folds, Russian Blue, Carthusian Retriever, Nova Scotia Duck tolling Retriever Coon and their cross species, Mutation Shepherd and Waeller Cats, Chartreux, Birman (NSDTR), Poodle, Shetland Sheepdog R820W Ragdoll and their cross species GD50 Hereditary Cataract (HSF4) GD27 prcd-PRA (atrophy of the retina) (Sheltie), Pembroke Welsh Corgi, Cardigan GD58 PRA (Progressive Retinal Atrophy) Welsh Corgi, Rough Collie, Smooth Boston Terrier, French Bull Dog, American Eskimo, American Cocker Byssinian, Somali, Ocicat, Siamese, Collie, Bernese Mountain Dog, Airedale Staffordshire Bull Terrier Spaniel, Australian cattle dog, Australian Bengal. Balinese, Javanese, Terrier, French Bull Dog, Fox Terrier, Boxer, Shepherd, Australian Stumpy Tail Cattle GD57 Dwarfism (Skeletal Dysplasia 2) Oriental Shorthair, Tonkinese Rhodesian Ridgeback, Jack Russell Terrier, Dog, Australian Labradoodle, Bolonka Labrador Retriever Kerry Blue Terrier, Wire Fox Terrier, Cavalier CANINE Zwetna, Chesapeake Bay Retriever, Chinese GD64 Degenerative Myelopathy King Charles Spaniel, Alaskan Malamute, Crested, Cockapoo, German Pomeranian, Radiculomyelopathy GD02 Canine malignant hyperthermia Pug, Borzoi (Russian Wolfhound), Hovawart, English Cocker Spaniel, Entlebucher Bernese Mountain (genetic predisposition) Soft Coated Wheaten Terrier, Canaan Dog, Sennenhund, Finish Lappdog, Golden Pyrenean Mountain Dog (Great Pyrenees), GD82 Pituitary Dwarfism GD03 Canine leucocyte Doodle, Golden retriever, Big Poodle, Lakeland Terrier, Hungarian Pumi, German Shepherd, Czechoslovakian adhesion deficiency (CLAD) Karelian Bear Dog, Little Poodle and Toy Wolfdog and Saarloos Wolfdog Bloodhound, British Timber Dog, © 2021 IDEXX Laboratories, Inc. All rights reserved. · Irish Setter, Irish Red and White Setter Poodle, Kuvasz, Labradoodle, Labrador Glen Of Imaal Terrier, Utonagan Retriever, Lapplandhirtenhund, Markiesje, MDR1 MDR1 Defect (multi resistance, GD08 Collie Eye Anomaly (CEA) Miniatur American Shepherd, Miniatur GD41 Hyperuricosuria (HUU, SLC) ivomectin hypersensitivity) Australian Shepherd (Miniature, + Toy), Australian Shepherd, Moyen poodle, All Dog Breeds, Dalmatian, Large Bearded Collie, Border Collie, Boykin PARC Parentage Test (Canine) Norway Elkdog, Nova Scotia Duck Tolling Munsterlander, Bulldog, Russian Black Spaniel, Collie, Hokkaido, Lancashire Retriever, Portuguese Waterdog, Pumi, Big Terrier (RBT), Hungarian Wirehaired Vizsla PDE/ Encephalitis (PDE)/Necrotizing Heeler, Long- und Shorthair Collie Longhair Schnauzer, Schipperke, Swedish Lappdog, (Vizslak), Hungarian Vizsla NME Meningoencephalitis (NME) Whippet, Miniature American Shepherd, Silky terrier, Spanish Waterdog, Wäller, Pug Nova Scotia Duck Tolling Retriever, Sheltie GD42 Episodic Falling Yorkshire Terrier, Miniature Poodle (Shetland Sheepdog), Silken Windhound Cavalier King Charles Spaniel VONP Von Willebrand-disease GD28 cord1-PRA GD09 Copper storage disease GD43 Dry Eye and Curly Coat Type 1: Berner Sennenhund, Coton de English Springer Spaniel, Longhair- and Tulear, German Pinscher, Doberman, kerry Bedlington Terrier Shorthair Minature Dachshund, Miniature Syndrome (CCS) Blue Terrier, Manchester Terrier, papillon, Cavalier King Charles Spaniel GD10 Cystinuria rough hair Dachshund, Curly Coated Poodle, Welsh Corgi, Labradoodle (genetic predisposition) Retriever GD44 Polycystic Kidney Disease Type 2: German Wirehair, German Shorthair Newfoundland, Landseer GD36 Exercise Induced Collapse (EIC) Bull Terrier Type 3: Old Dutch Dog, Scottish Terrier, Shetland Sheepdog (Sheltie) GD11 Fucosidosis Labrador Retriever, Chesapeake Bay GD45 Neuronal Ceroid Lipofuscinosis English Springer Spaniel Retriever, Curly-coated Retriever, German (NCL) AVIAN Wirehaired Pointer, Pembroke Welsh Corgi, American Bulldog, American Staffordshire ASEX Avian Sexing N.B. Please GD18 L-2-hydroxyglutaric aciduria Boykin Spaniel (L-2-HGA) Terrier, Australian Shepherd, Border collie, specify EXACT species Chihuahua, Chinese Crested, Dachshund, Staffordshire Bull Terrier GD38 Familial Nephropathy English Cocker Spaniel English Setter, Golden Retriever, Gordon GD20 Mucopolysaccharidosis VII Setter, Miniature Wire haired Dachshund, German Shepherd Miniature American Shepherd, Miniature GD21 Myopathy (CNM, HMLR, LRM) Long Haired Dachshund, Miniature Labrador Retriever Smooth Haired Dachshund, Saluki, Standard Long Haired Dachshund, GD25 Phosphofructokinase Standard Smooth Haired Dachshund, deficiency Standard Wirehaired Dachshund, English Springer Spaniel, American Tibetan Terrier Cocker Spaniel and their cross species PREVIOUS REF. N° Please provide history to allow for interpretation (please indicate Differential Diagnosis / Disease Suspected / Specific questions you would like addressed) *IDEXX handles personal data responsibly and has adopted the privacy policy which can be found at idexx.com/privacy FOR LAB USE ONLY EDTA UNLABELLED REV LOCK BOX NHS OTHER COURIER E-SWAB IDEXX Laboratories Ltd Tel: UK: +44 (0) 2037887508 · Eire: +353 (0) 15621211 GTD Fax: 01937 544001 · [email protected] · www.idexx.co.uk.
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