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Submission Form Genetics

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Submission Form Genetics Submission form + Invoice to pet owner pe LABOR FÜR KLINISCHE DIAGNOSTIK GMBH & CO. KG Genetics Dog Customer-No. / Barcode PB 1810 DE-97668 Bad Kissingen Tel +49 971 72020 Fax +49 971 68546 Business Hours: Mo - Fr: 9:00 - 18:00 h, Sa: 9:00 - 13:00 h E-Mail: [email protected] Clinic address: Owner: Invoice to: (Stamp or block letters) (Block letters only, please) Veterinarian Name: _________________________________________Owner First name:_________________________________________ Date of birth:__________________________________________________________________________________ (If the invoice should be sent to the owner or submitter, please (Owners signature for direct include their complete address and signature ) invoicing) Street: _________________________________________ VAT-No.: _________________________________________________ Please note: Zipcode/city: Address for invoicing and _________________________________________signee must be identical Fax / e-Mail: _________________________________________________ Tel.: _________________________________________ Date/Signature:_______________________________________________________________ Notification: Email Fax Mail Report copy to owner Courier 8105 Certificate 106,00 NOK (NOTE: Certificate is required by NKK, SKK, DKK etc., so please remember to request it, if applicable!) 1) The identity of the animal must be confirmed by a veterinarian (specified by Microchip-No. or Tattoo-No.) 2) Certificates are not issued for partner laboratory services 3) Certificates are included in the DNA-profile and parentage testing I have checked the animal(s) identity and confirm that the submitted sample(s) are taken from the animal(s) listed below. Name ___________________________________________________and Aut-No.: ____________Signature / Stamp___________________________________________________ veterinarian: ____________ Chip-/Tattoo-No.:_______________________________________________________________Date of sampling:_______________________________________________________________ _- Please note: Indication of breed is mandatory! Animal 1 (MANDATORY - please complete using capital letters) Sample: 0,5 ml EDTA-blood 2 x Cytobrush Blood card Sex: F M Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.:_______________________________________________________________ Sample_______________________________________________ label: Animal 2 (MANDATORY - please complete using capital letters) t owner + Invoice to pet Sample: 0,5 ml EDTA-blood 2 x Cytobrush Blood card Sex: F M Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.:_______________________________________________________________ Sample_______________________________________________ label: Animal 3 (MANDATORY - please complete using capital letters) Sample: 0,5 ml EDTA-blood 2 x Cytobrush Blood card Sex: F M Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.:_______________________________________________________________ Sample_______________________________________________ label: 010110180034 Hereditary diseases NOK NOK 8166 8192 Achromatopsia (Day blindness) (ACHM-1) 500,00 Familial Nephropathy (FN) 500,00 (German Shepherd, Labrador Retriever) (English Springer Spaniel, Samoyed) 8259 8272 Adult Onset Neuropathy* (AON) 912,00 Fanconi Syndrome* 912,00 (English Cocker Spaniel, Field Spaniel) (Basenji) 8313 8467 Alaskan Husky Encephalopathy (AHE) 500,00 Finnish Hound Ataxia (FHA) 500,00 (Husky) (Finnish Hound) 8479 8016 Alaskan Malamute Polyneuropathy (AMPN) 500,00 Fucosidosis 500,00 (Alaskan Malamute) (English Springer Spaniel) 8303 8323 Amelogenesis Imperfecta (AI) 500,00 Gallbladder Mucoceles 500,00 (Italian Greyhound) (American Cocker Spaniel, Cairn Terrier, English Cocker Spaniel, Pomeranian, 8207 Bardet-Biedl Syndrome (BBS) 500,00 Shetland Sheepdog) 8077 (Puli) Glanzmann Thrombastenia (GT) 500,00 8219 Brachyuria (Stumpy tail) 500,00 (Pyrenean Mountain Dog) 8007 (Australian Shepherd, Australian Stumpy Tail Cattle Dog, Austrian Pinscher, Globoid Cell Leukodystrophy (Krabbe disease) 500,00 Bourbonnais Pointer, Bouvier des Ardennes, Brazilian Terrier, Brittany Spaniel, (Cairn Terrier, Irish Setter, West Highland White Terrier) Croatian Sheepdog, Danish/Swedish Farmdog, Jack Russell Terrier, 8322 Glycogen Storage Disease GSD Ia 500,00 Karelian Bear Dog, Mudi, Polish Lowland Sheepdog, Pyrenean Shepherd, Savoy (Maltese) Sheepdog, Schipperke, Spanish Waterdog, Swedish Vallhund, Welsh Corgi) 8513 Glycogen Storage Disease GSD II (Pompe disease) 500,00 8184 C3-Deficiency (C3) 500,00 (Finnish Lapphund, Lapponian Herder, Swedish Lapphund) 8156 (Brittany Spaniel) Glycogen Storage Disease GSD IIIa 500,00 8012 Canine Leukocyte Adhesion Deficiency (CLAD) 500,00 (Curly Coated Retriever) 8066 (Irish Setter, Irish Red and White Setter) GM1-Gangliosidosis (GM1) 500,00 8330 Canine Multi-focal Retinopathy (CMR1/2/3) 651,00 (Portuguese Waterdog, Shiba Inu, Siberian Husky) 8208 (American Bulldog, Australian Shepherd, Boerboel, Bullmastiff, Cane Corso, Coton de GM2-Gangliosidosis (Sandhoff disease) (GM2) 500,00 Tulear, Dogo Canario, Dogue de Bordeaux, English Mastiff, Finnish Lapphund, (Toy Poodle) Lapponian Herder, Pyrenean Mountain Dog, Swedish Lapphund) 8098 Grey Collie Syndrome 500,00 8575 Canine Multiple System Degeneration (CMSD) 500,00 (Canine Cyclic Neutropenia) (Chinese Crested, Kerry Blue Terrier) (Collie) 8073 8232 t owner + Invoice to pet Centronuclear Myopathy (CNM) 500,00 Haemophilia A (Faktor VIII) - deficiency 651,00 (Great Dane, Labrador Retriever) (Boxer, German Shepherd, Havanese) 8314 8221 Cerebral Dysfunction (CDFS) 500,00 Haemophilia B (Faktor IX) - deficiency 651,00 (Stabyhoun) (Lhasa Apso, Rhodesian Ridgeback) 8316 8319 Chondrodysplasia (Dwarfism) 500,00 Haemorrhagic Diathesis (Scott syndrome) 500,00 (Karelian Bear Dog, Norwegian Elkhound) (German Shepherd) 8326 8449 Cleft Lip/Palate and Syndactyly (CLPS) 500,00 Hereditary Ataxia (HA) 500,00 (Nova Scotia Duck Tolling Retriever) (Gordon Setter, Old English Sheepdog) 8120 8157 Collie Eye Anomaly (CEA)* Optigen 1847,00 Hereditary Cataract (HSF4) 500,00 8304 Collie Eye Anomaly (CEA)* Partner lab 500,00 (Australian Shepherd, Wäller) 8576 (Australian Shepherd, Bearded Collie, Border Collie, Boykin Spaniel, Hokkaido, Hereditary Cataract (HSF4)* 500,00 Lancashire Heeler, Longhaired Wippet, Nova Scotia Duck Tolling Retriever, (Boston Terrier, French Bulldog, Staffordshire Bull Terrier) Rough/Smooth Collie, Shetland Sheepdog, Silken Windhound) 8421 Hereditary Nasal Parakeratosis (HNPK) 865,00 8256 Cone Degeneration (CD)* Optigen 1965,00 (Labrador Retriever) 8179 (Alaskan Malamute, Australian Shepherd, German Shorthaired Pointer) Hereditary Neuropathy (GHN) 500,00 8434 Congenital Hypothyroidism with Goiter (CHG) 500,00 (Greyhound) 8154 (Fox Terrier, French Bulldog, Rat Terrier, Spanish Waterdog, Tenterfield Terrier) Hyperurikosuria (SLC) 500,00 8317 Congenital Ichthyosis 500,00 (All breeds) 8443 (Great Dane) Hypomyelination / Shaking Puppy Syndrome (SPS) 500,00 8206 Congenital Myasthenic Syndrome (CMS) 500,00 (English Springer Spaniel, Weimaraner) 8481 (Jack Russell Terrier, Labrador Retriever, Old Danish Pointing Dog, Ichthyosis* 500,00 Parson Russel Terrier) (Golden Retriever) 8011 8475 Congenital Stationary Night Blindness (CSNB) 500,00 Imerslund-Gräsbeck Syndrome (IGS) 500,00 (Briard) (Beagle, Border Collie) 8034 8198 Copper Storage Disease (Copper toxicosis) 500,00 Junctional Epidermolysis Bullosa (JEB) 500,00 (Bedlington Terrier) (German Shorthaired Pointer) 8348 8459 Craniomandibular Osteopathy (CMO) 651,00 Juvenile Epilepsy (JE) 500,00 (Cairn Terrier, Scottish Terrier, West Highland White Terrier) (Lagotto Romagnolo) 8013 8271 Cystinuria 500,00 Juvenile Laryngeal Paralysis & Polyneuropathy 500,00 (Australian Cattle Dog, Labrador Retriever, Landseer, Newfoundland, Miniature (JLPP) Pinscher) (Black Russian Terrier, Rottweiler) 8260 8125 Dandy-Walker-like Malformation (DWLM) 500,00 L-2-hydroxyglutaric Aciduria (L-2-HGA) 500,00 (Eurasian) (Staffordshire Bull Terrier) 8485 8270 Degenerative Myelopathy (DM) Exon 1 500,00 Lagotto Storage Disease (LSD) 500,00 (Bernese Mountain Dog) (Lagotto Romagnolo) 8158 8493 Degenerative Myelopathy (DM) Exon 2 651,00 Late Onset Ataxia (LOA) 500,00 (All breeds) (Jack Russell Terrier, Parson Russel Terrier) 8472 8487 Digital Hyperkeratosis (DH/HFH) 500,00 Leonberger Polyneuropathy 1 (LPN1) 500,00 (Dogue de Bordeaux, Irish Terrier, Kromfohrländer) (Leonberger) 8406 8327 Dry Eye Curly Coat Syndrome (CCS)
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