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Submission Form Submission Form Genetic tests for dogs D-45659 Recklinghausen Berghäuser Straße 295 (Please write legibly and in block letters) Phone: +49 [0] 2361 3000 121 Fax: +49 [0] 2361 3000 169 Membership breed club: YES ☐ NO ☐ E-mail: [email protected] (If YES - please attach a copy of your membership card) Internet: www.biofocus.de Owner/Sender Full name: __________________________________________ Country:_______________________________ Street:_____________________________________________ Phone:________________________________ City:______________________________________________ Fax:__________________________________ State:____________________ Zip-Code:_______________ E-mail:_______________________________ Date/Signature:______________________________________ Dog information Name: ___________________________________ Tattoo-No.: __________________________________ Breed: ___________________________________ Registration-No.: _____________________________ Coat color: ________________________________ Chip-No.: ___________________________________ (required for certificates) Date of birth: ______________________________ Gender: female ☐ male ☐ Dog’s parents: (only necessary for coat color and coat type tests) Dam’s name: ________________________________ Sire’s name: __________________________________ Breed: _____________________________________ Breed: ______________________________________ Coat color: _________________________________ Coat color: __________________________________ Coat length longhair ☐ shorthair ☐ Coat length longhair ☐ shorthair ☐ (only necessary for coat length test) (only necessary for coat length test) Sample specification Sampling by: Owner/Sender ☐ Independent authority (e.g. veterinarian or breed warden) ☐ Sample material: buccal swabs (2 samples) ☐ EDTA-blood (approx. 0.5 ml) ☐ Please perform the buccal swab thoroughly and make sure that the dog being tested has not eaten anything for at least 30 minutes. Further information about sample collection is available on our homepage. Sample labeling: _________________________________________ Date of sampling: ________________________________________ I hereby confirm that the identity of the above-listed animal was verified and that the samples derive from the above-listed animal. ______________________________________ Stamp and signature independent authority Independent authority name in block letters:______________________________________________________ Submission of results Test-results will be send to either the Owner/Sender and/or Veterinarian Test-results to: Owner/Sender ☐ Veterinarian ☐ Owner/Sender and Veterinarian ☐ Invoice to: Owner/Sender ☐ Veterinarian ☐ Certificate: ☐ certificates will be provided for each test separately. Certificate for the first test is free of charge, certificates for two to five tests will cost 7.14 €, more than five certificates will cost 14.28 € (incl. VAT). Certificates can only be issued if Chip-no. are provided. It is recommended that sampling is carried out by an independent authority (e.g. veterinarian or breed warden) to confirm sample origin. Data privacy statement: The personal data collected in this form is used to perform the commissioned analysis. Based on art. 6 (1b) EU-DSGVO data will only be used for processing and fulfillment of the contract as well as to process the payment transaction. Biofocus LADR data protection official is Dirk Fox, Secorvo Security Consultant GmbH, Ettlinger Str. 12-14, 76137 Karlsruhe (email: [email protected]). Information about your personal data stored by Biofocus LADR can be inquired in written form by contacting Manuel Ostendorff (email: [email protected]). Owner/Sender: _____________________________________________ Dog’s name: ________________________________________________ Genetic Disorders Actual prices are listed on our homepage and can be inquired by e-mail. Please pay attention to our test-packages described at the end of the form. Ataxia, cerebellar, ATP1B2-related (SDCA2) Haemophilia A* (Belgian Shepherd Dog) ☐ X-linked ☐ Ataxia, cerebellar, KCNJ10-related (SDCA1) (Havanese) (Belgian Shepherd Dog) ☐ Hyperkeratosis, palmoplantar (HFH) (Irish Terrier, Kromfohrländer) ☐ Bandera's neonatal ataxia ☐ (Coton de Tulear) Hyperuricosuria (HU) ☐ Bleeding disorder, P2RY12-related (all breeds) (Great Swiss Mountain Dog) ☐ Ichthyosis (Icht-GR) Brachyury / Tail, short (Golden Retriever) ☐ (Australian Shepherd, Austrian Pinscher, Australian Stumpy Tail Cattle Dog, ☐ Krabbe disease Bourbonnais Pointing Dog, Brazilian Terrier, Brittany Spaniel, Croatian (Cairn Terrier, Irish Red Setter, West Highland White Terrier) ☐ Shepherd Dog, Danish-Swedish Farmdog, Jack Russell Terrier, Karelian Bear Dog, Mudi, Polish Lowland Sheepdog, Pyrenean Sheepdog, Savoy Sheepdog, Leukocyte adhesion deficiency, type I (CLAD) ☐ Schipperke, Spanish Water Dog, Swedish Vallhund) (Irish Red Setter, Irish Red and White Setter) Chondrodysplasia Malignant hyperthermia (MH) FGF4-Insertion-CFA18 ☐ (all breeds) ☐ (Basset Hound, Cairn Terrier, Dachshund, Dandie Dinmont Terrier, Mucopolysaccharidosis VII (MPS VII) Lancashire Heeler, Norwich Terrier, Petit Basset Griffon Vendeen, Skye (German Shepherd Dog) ☐ Terrier, Swedish Vallhund, Tebetian Spaniel, Welsh Corgi (Cardigan), Welsh Corgi (Pembroke), West Highland White Terrier) Multidrug resistance 1 (MDR1)* ☐ Chondrodysplasia / (Australian Shepherd, Bobtail (Old English Sheepdog), Border Collie, Collie ☐ (rough), Collie (smooth), German Shepherd Dog, Longhaired Whippet, Intervertebral Disc Disease Type 1 (IVDD) Shetland Sheepdog, Silken Windhound, Toy Australian Shepherd, White FGF4-Insertion-CFA12 Swiss Shepherd Dog, Wäller) (breeds with short and long leg phenotypes) Muscular hypertrophy (bully whippet) Chondrodysplasia / (Whippet) ☐ ☐ Intervertebral Disc Disease Type 1 (IVDD) Musladin-Lueke syndrome (MLS) FGF4-Insertion-CFA12 and CFA18 (Beagle) ☐ (breeds with short and long leg phenotypes) Myoclonus epilepsy of Lafora* Copper toxicosis / Wilson disease ☐ min. 14 days, blood sample required ☐ (Bedlington Terrier ) (Basset Hound, Beagle, Dachshund (wire-haired)) Cystinuria, type I - A Myopathy, centronuclear (HMLR) ☐ (Landseer, Newfoundland) (Labrador Retriever) ☐ Cystinuria, type III Narcolepsy SLC3A1 and SLC7A9 mutations ☐ (Dachshund, Dobermann, Labrador Retriever) ☐ (American Bulldog, Bulldog, Continental Bulldog, French Bulldog, Leavitt Bulldog, Olde English Bulldog) Neonatal cerebellar cortical degeneration (NCCD) ☐ Degenerative myelopathy (DM Combi-Test 1) (Beagle) SOD1:c.118G>A mutation Exon 2* / SOD1: c.166+9_c.166+10ins ☐ Neonatal encephalopathy with seizures (NEWS) (Collie (rough), Hovawart, Poodle) (Poodle) ☐ Degenerative myelopathy (DM Combi-Test 2) ☐ Nephropathy SOD1:c.52A>T mutation Exon 1 / SOD1:c.118G>A mutation Exon 2* (English Cocker Spaniel) ☐ (Bernese Mountain Dog, Great Swiss Mountain Dog) Neuroaxonal dystrophy (NAD) Degenerative myelopathy (DM) (Papillon, Spanish Water Dog) ☐ SOD1:c.52A>T mutation Exon 1 ☐ (Bernese Mountain Dog, Great Swiss Mountain Dog) Neuronal ceroid lipofuscinosis (NCL) (American Bulldog, American Staffordshire Terrier, Australian Cattle Dog, ☐ Degenerative myelopathy (DM)* ☐ Australien Sheperd, Border Collie, Chihuahua, Chinese Crested, Dachshund SOD1:c.118G>A mutation Exon 2* (long-haired), English Setter, Tibet Terrier) (all breeds) Neutropenia, cyclic / Grey Collie Syndrom Dry Eye Curly Coat + Episodic Falling (Combi)* (Collie (rough), Collie (smooth)) ☐ (Cavalier King Charles Spaniel) ☐ Oculoskeletal dysplasia 2 (OSD2/DRD2) Dry Eye Curly Coat Syndrom (Samoyed) ☐ (Cavalier King Charles Spaniel) ☐ Osteogenesis imperfecta (OI) Duchenne muscular dystrophy (DMD) (Dachshund) ☐ (Cavalier King Charles Spaniel) ☐ Phosphofructokinase deficiency (PFK) / Epidermolytic Hyperkeratosis (EHK) Glycogen Storage Disease VII (GSD VII) ☐ (Norfolk Terrier) ☐ (American Cocker Spaniel, English Cocker Spaniel, English Springer Spaniel, Episodic falling* German Spaniel, Whippet) ☐ (Cavalier King Charles Spaniel) Primary ciliary dyskinesia (PCD) Factor VII deficiency (Bobtail (Old English Sheepdog)) ☐ (Airedale Terrier, Alaskan Klee Kai, Beagle, Deerhound, Giant Schnauzer) ☐ Primary hyperoxaluria type I (PH1) ☐ Fucosidosis, alpha ☐ (Coton de Tulear ) (English Springer Spaniel ) Pug Dog Enzephalitis (PDE) / ☐ GM1-Gangliosidosis ☐ Necrotizing meningoencephalitis (NME) (Alaskan Husky) (Pug) Golden Retriever Muscular dystrophy (GRMD) ☐ Pyruvate dehydrogenase deficiency (PDPD) (Golden Retriever) (Clumber-Spaniel, Sussex-Spaniel) ☐ MOL-SUBDOG-FO-K5.4-338V4 (effective from 01.01.2020) Owner/Sender: _____________________________________________ Dog’s name: ________________________________________________ Pyruvate kinase deficiency Von Willebrand disease II (vWDII) (Basenji, Cairn Terrier, West Highland White Terrier) ☐ (German Pointing Dog (short-haired), German Pointing Dog (wire-haired)) ☐ Severe combined immunodeficiency disease (SCID) Von Willebrand disease III (vWDIII) autosomal ☐ (Scottish Terrier, Shetland Sheepdog) ☐ (Jack Russell Terrier) *partner laboratory Severe combined immunodeficiency disease (XSCID) ☐ X-linked (Basset Hound, Welsh Corgi (Cardigan)) Trapped Neutrophil Syndrome (TNS) (Border Collie) ☐ Von Willebrand disease I (vWDI) (Australian Labradoodle, Basset Hound, Bernese Mountain Dog, Coton de ☐ Tulear, Dachshund, Dobermann, Drentsche Partridge Dog, German Shepherd Dog, Goldendoodle, Kerry Blue Terrier, Kromfohrländer, Manchester Terrier, Miniature Schnauzer, Papillon, Poodle, Poodle (Miniature), Poodle (Multicolor), Poodle (Toy), Rottweiler,
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