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Laboklin Crufts 2012 Order Form

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Laboklin Crufts 2012 Order Form Customer Account No: Order Form ............................ ............................... Dog Genetic Tests 125 Northenden Rd, Manchester M33 3HF Special price list for tests Submitted at Crufts 2012 tel 0161 282 3066 - fax 0161 973 3434 [email protected] - www.laboklin.co.uk Veterinary Surgeon (stamp or block letters) Owner details (block letters) Only required if sample collected by a vet Full name: Address: Town / City: County: Postcode: Country: Tel: Tel: Fax: Fax: Email: Email: Date: Signature: Date: Signature: Reporting: [ ] Result to Vet [ ] Result to Owner - Please select ONE reporting method: [ ] Result by fax - [ ] Result by email - [ ] Result by post Dog 1 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs - Sample Date: ....................................... Sample label ................................................... Test (s) required (Provide both test number and test name from test list): Dog 2 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs - Sample Date: ....................................... Sample label ................................................... Test (s) required (Provide both test number and test name from test list): Dog 3 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs - Sample Date: ....................................... Sample label ................................................... Test (s) required (Provide both test number and test name from test list): Dog 4 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs - Sample Date: ....................................... Sample label ................................................... Test (s) required (Provide both test number and test name from test list): * Declaration: I accept that, for UK registered dogs, results of the tests in the attached list which are part of the Official UK Kennel Club DNA testing scheme will be sent to the Kennel Club and published as part of the Kennel Club scheme. Signed ................................................................................................ (owner / agent) Date: ................................................................................................. Payment: [ ] I enclose a cheque / Postal order payable to LABO KLIN (UK) for the amount of £ ................................................ [ ] I have already paid online by credit / debit card / paypal* the amount of £ ............... my payment reference number is: ........................ * Paypal payment must be made to [email protected], please add 3% fees. EDTA blood tubes and cheek swabs are available free of charge, please email [email protected]. Any other information?: This form is downloadable from www.laboklin.co.uk ISO / DIN 17025 Accredited Laboratory Dog Genetic Tests 125 Northenden Rd, Manchester M33 3HF tel 0161 282 3066 - fax 0161 973 3434 [email protected] - www.laboklin.co.uk Crufts 2012 Price List Test No Disease or Condition Name Cost Incl. VAT [ ] 8193D Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC) * ( Boxer ) £ 64.80 [ ] 8219D Brachyury (Bobtail Gene / Short Tail) ( Australian Shepherd , Australian Stumpy tail cattle Dog , Austrian Pinscher , Bourbonnais Pointer , Brazilian Terrier , Brittany £ 49.50 Spaniel , Croatian Sheepdog , Danish Farm Dog , Jack Russel Terrier , Karelian Bear Dog , Mudi , Polish Lowland sheepdog , Pyrenean Shepherd , Savoy Sheepdog , Schipperke , Spanish Waterdog , Swedish Farm Dog , Swedish Vallhund ) [ ] 8012 CLAD (Canine Leukocyte Adhesion Deficiency) ( Irish Setter ) Official UK Kennel Club DNA testing scheme in Irish Setter. Please sign the declaration. £ 49.50 [ ] 8011 CSNB (Congenital Stationary Night Blindness) ( Briard ) Official UK Kennel Club DNA testing scheme in Briard. Please sign the declaration. £ 49.50 [ ] 8098 Canine Cyclic Neutropenia (Gray Collie Syndrome) ( Border collie , Collie , Rough Collie , Smooth Collie ) £ 49.50 [ ] 8000 Copper Toxicosis ( Bedlington Terrier ) £ 49.50 [ ] 8013 Cystinuria ( Landseer , Newfoundland ) Official UK Kennel Club DNA testing scheme in Newfoundland. Please sign the declaration. £ 49.50 [ ] 8158D Degenerative Myelopathy / degenerative radiculomyelopathy) (All Dog Breeds, Boxer, Cardigan Welsh Corgi, Chesapeake Bay Retriever, German Shepherd, Pembroke £ 67.50 Welsh Corgi, Poodle, Rhodesian Ridgeback, Wire Fox Terrier) Official UK Kennel Club DNA testing scheme in Chesapeake Bay Retriever. Please sign the declaration. [ ] 8194D Dilated Cardiomyopathy (DCM) * ( Doberman , Doberman Pinscher ) £ 64.80 [ ] 8142 Dwarfism (Pituitary Dwarfism / Hypopituitarism) * ( Czechoslovakian Wolfdog , German Shepherd , Saarloos Wolfdog ) £ 144.00 [ ] 8227D Episodic Falling / Falling Cavaliers (Cavalier King Charles Spaniel) £ 49.50 [ ] 8228D Dry Eye and Curly Coat Syndrome (Cavalier King Charles Spaniel) £49.50 [ ] 8229D Episodic Falling + Dry Eye and Curly Coat Syndrome (Cavalier King Charles Spaniel) £49.50 [ ] 8152 Exercise Induced Collapse ( EIC ) ( Boykin Spaniel , Chesapeake Bay Retriever , Curly Coated Retriever , German Wirehaired Pointer , Labrador Retriever , £ 65.25 Pembroke Welsh Corgi ) [ ] 8151 Factor VII Deficiency ( Airedale , Alaskan Klee Kai , Beagle , Giant Schnauzer , Scottish Deerhound ) £ 49.50 [ ] 8192D Familial Nephropathy (FN) / Hereditary Nephropathy ( English Springer Spaniel ) £ 49.50 [ ] 8131D Familial Nephropathy (FN) / Hereditary Nephropathy * ( English Cocker Spaniel ) Official UK Kennel Club DNA testing scheme in English Cocker Spaniel. Please sign £ 65.25 the declaration. [ ] 8016 Fucosidosis ( English Springer Spaniel ) Official UK Kennel Club DNA testing scheme in English Springer Spaniel. Please sign the declaration. £ 58.50 [ ] 8066 GM1-Gangliosidosis ( Huskies ) £ 49.50 [ ] 8068 GRMD (Golden Retriever Muscular Dystrophy) ( Golden Retriever ) £ 49.50 [ ] 8007 Globoid Cell Leukodystrophy (Krabbe Disease) ( Cairn Terrier , West Highland White Terrier ) £ 49.50 [ ] 8156D Glycogen Storage Disease (GSDllla) ( Curly Coated Retriever ) £ 49.50 [ ] 8179D Greyhound Neuropathy (Hereditary Neuropathy) ( Greyhound ) Official UK Kennel Club DNA testing scheme in Greyhound. Please sign the declaration. £ 60.30 [ ] 8222D Haemophilia A (factor VIII deficiency) ( Havanese Dogs ) £ 72.00 [ ] 8221D Haemophilia B (factor IX deficiency) ( Rhodesian Ridgeback ) £ 72.00 [ ] 8157 Hereditary Cataract ( Australian Shepherd ) Official UK Kennel Club DNA testing scheme in Australian Shepherd. Please sign the declaration. £ 49.50 [ ] 8073 Hereditary Myopathy / Centronuclear Myopathy (HMLR, CNM) ( Labrador Retriever ) Official UK Kennel Club DNA testing scheme in Labrador Retriever. Please sign £ 49.50 the declaration. [ ] 8192DS Hereditary Nephritis / Samoyed Hereditary Glomerulopathy ( Samoyed ) £ 49.50 [ ] 8154D Hyperuricosuria ( All Dog Breeds , American Bulldog , Black Russian Terrier , Bulldog , Dalmatian , French Bull Dog ) Official UK Kennel Club DNA testing scheme in £ 49.50 Black Russian Terrier , and Bulldog. Please sign the declaration. [ ] 8198D JEB (Junctional Epidermolysis bullosa) ( German Longhaired Pointer , German Pointers , German Shorthair Pointer , German Wirehaired Pointer ) £ 49.50 [ ] 8100DGD L-2-HGA (L- 2 - hydroxyglutaric aciduria) (Staffordshire Bull Terrier)
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