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IDEXX Reference Laboratories PCR REQUEST FORM - GENETIC DISEASE

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IDEXX Reference Laboratories PCR REQUEST FORM - GENETIC DISEASE IDEXX Reference Laboratories PCR REQUEST FORM - GENETIC DISEASE To help us process your sample as efficiently as possible, please provide all owner and patient patient‘S NAME information including Kennel Club Registration Number and Microchip number. Please note the expected time for results is up to 6 weeks from receipt of the sample and completed form. KENNEL CLUB NAME date REGISTERED BREED LAB NUMBER VETERINARY SURGEON (LAB USE ONLY) date OF birth KENNEL club No ADDress stamp SEX NEUTERED MICROCHIP No OWNER‘S NAME OWNER‘S address VET CODE POSTCODE SEE PRICE LIST FOR PROFILE CONTENT & SAMPLE REQUIREMENTS // Please tick test required ü GD01 BLAD GD14 Globoid cell leucodystrophy GD25 Phosphofructokinase deficiency GD34 SCID (severe combined Holstein-Friesian cattle West Highland White Terrier, Cairn Terrier English Springer Spaniel, American immunodeficiency) Cocker Spaniel and their cross breeds Jack Russell Terrier and Arabian horse as of 4-2013 GD02 Canine malignant hyperthermia GD15 GSD4 Glycogen storage disease (genetic predisposition) Type IV GD26 Polycystic Kidney Disease (PKD) VONP Von Willebrand-disease Norwegian Forest Cat UK116 GD03 CLAD (Canine leucocyte Persian, Himalayan, Siamese cats, T ype 1: Dobermann, Poodle, Manchester Ragdolls, European Shorthair, Terrier, Bernese Mountain dog, German adhesion deficiency) GD16 HCM American Shorthair, British Shorthair, Pointer, Welsh Corgi; Irish Setter (Hypertrophic Cardiomyopathy) Exotic Shorthair, Selkirk Rex and Type 2: German Wirehaired; Mutation A31P Maine Coon and their Scottish Folds Type 3: Scotch Terrier, Sheltie GD04 Coat colour BROWN cross breeds, Mutation A74T Maine Coon Labrador and Flatcoated Retriever and their cross breeds, Mutation R820W GD27 prcd-PRA (atrophy of the retina) GD37 X-SCID Ragdoll and their cross breeds GD05 Coat colour CHESTNUT Australian Cattle Dog, American Cocker Welsh Corgi and Basset Spaniel, American Eskimo, Chesapeake horses GD17 Hyperkalemic periodic paralysis Bay Retriever, Chinese Crested, PARC/ Parentage Test GD06 Coat colour (HYPP) English Cocker Spaniel, Entlebucher PARF Mountain dog, Kuvasz, Lapponian Herder, CHOCOLATE/CINNAMON American Quarter horses and their cross breeds Labrador Retriever, Miniature Poodle, MDR1 MDR1 Defect cats Nova Scotia Duck Tolling Retriever, Portuguese Water dog, Swedish and © 2008 IDEXX Laboratories, Inc. All rights reserved. · GD07 Coat colour YELLOW GD18 L-2-HGA Finnish Lapp dog, Silky Terrier, Labrador and Flatcoated Retriever (L-2-hydroxyglutaric aciduria) Australian Stumpy Tail Cattle Dog, Staffordshire Bull Terrier Toy Poodle, Golden Retriever, Pumi, GD08 Collie Eye Anomaly (CEA) Spanish Water Dog Border Collie, Rough Collie and Smooth MDR1 MDR1 Defect (multi resistance, Collie, Longhaired Whippet, Lancashire Heeler, Shetland Sheepdog, Australian ivomectin hypersensitivity) GD28 cord1-PRA Shepherd GD20 Mucopolysaccharidosis VII Miniature long haired and smooth haired Dachshund, English Springer Spaniel GD09 Copper storage disease German Shepherd Bedlington Terrier GD21 Myopathy (CNM, HMLR, LRM) GD29 rcd1-PRA GD10 Cystinuria Labrador Retriever Irish Setter and Cardigan Welsh Corgi (genetic predisposition) GD22 Myotonia congenita GD30 rcd2-PRA Newfoundland, Landseer Miniature Schnauzer, Chow Chow, Collie Staffordshire Bull Terrier, Mastiff GD36 Exercise Induced Collapse (EIC) GD31 rdAc-PRA Labrador Retriever, Chesapeake Bay GD23 Night blindness (CSNB) Somali, Abessinian Cat Retriever, Curly-coated Retriever Briard dog GD32 Pyruvatekinase deficiency – cat GD11 Fucosidosis GD24 Overo Lethal White Syndrome Somali, Abyssinian cat English Springer Spaniel American Paint Horse, Appaloosa, Pinto, GD33 Pyruvatekinase deficiency – dog Quarter Horse, Thoroughbred, American Basenji, Cairn- and GD12 Gangliosidosis GM1 Miniature Horse, Mustang, Half-Arab West Highland White Terrier Husky GD13 Gangliosidosis GM1 + GM2 Korat, Siamese, Burmese cat PREVIOUS REF. N° Cross REF. N° History, Clinical Findings & Current Therapy (Please continue overleaf if necessary) Fasting/Non Fasting Sample FOR LAB USE ONLY EDTA UNLABELLED REV LOCK BOX NHS OTHER COURIER IDEXX Laboratories Ltd Tel: 00800 1234 3399 · Fax: 01937 544001 GTD [email protected] · www.idexx.co.uk.
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