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Crufts 2019 Order Form

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Crufts 2019 Order Form LABOKLIN @ CRUFTS 2019 TH TH 7 – 10 March 10% Discount* on all DNA tests submitted at Crufts Dear Breeder / Dog Owner, We are pleased to inform you that LABOKLIN will be at Crufts 2019 and we look forward to seeing you there. Our stand is located in Hall 3 opposite the restaurant, it is stand number 3-7a. 10% Discount on all DNA tests submitted at Crufts ! and this includes our new Breed Specific DNA Bundles. You can submit a sample at Crufts in the following ways: 1) Bring your dog to our stand 3-7a, we will take a DNA sample for your genetic test, all you need to do is complete this order form and pay the fees. Or, 2) If you don't want to wait in the queue, you can prepare your sample in advance and bring it together with this order form with you to our stand, you can order a free DNA testing kit on our website www.laboklin.co.uk. We will send you a testing kit which also contains instructions on how to take DNA sample. Prepare your sample up to a week before your planned visit, just hand the sample to us. 3) If you prefer to use blood for your test, ask your vet to collect 0.5-1 ml of whole blood in EDTA blood tube, bring it together with the completed order form to the show, just hand it to us. Please note we will only accept Cash, Cheques or Postal Orders at the show. If you wish to pay by card, you can complete the card payment section. Paypal payments must be made in advance. The enclosed order form will only be accepted at Crufts 2019. If you have any questions, please email [email protected] or call 0161 2823066. We look forward to seeing you at Crufts 2019 . LABOKLIN (UK) * this offer cannot be used in conjunction with other offers such as Assured Breeder Scheme (ABS) discount or combination discount. LABOKLIN (UK), 125 Northenden Rd. Manchester M33 3HF. Tel: 0161 282 3066. [email protected] www.LABOKLIN.co.uk Order Form CRUFTS 20 19 THIS FORM IS ONLY VALID FOR SUBMISSIONS AT CRUFTS 2019 HALL 3 STAND 7A FROM 7TH TO 10TH MARCH 2019 125 Northenden Rd, Manchester M33 3HF Genetics: Dogs tel 0161 282 3066 - fax 0161 973 3434 Veterinary Surgeon (stamp or block letters) [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 Only if testing for parentage please specify [ ] Offspring [ ] Dam [ ] Questionable Sire Dog 1 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs [ ] Blood Card - Sample Date: .......................................... Sample label ......................................... Test (s) required (Provide both test number and test name from test list): Only if testing for parentage please specify [ ] Offspring [ ] Dam [ ] Questionable Sire Dog 2 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs [ ] Blood Card - Sample Date: .......................................... Sample label ......................................... Test (s) required (Provide both test number and test name from test list): Only if testing for parentage please specify [ ] Offspring [ ] Dam [ ] Questionable Sire Dog 3 Registered Name: ......................................................................................... Call Name: ......................................................................................... Breed: ................................................................................................ Sex: [ ] Male [ ] Female. Date of Birth: .............................................. Microchip No ......................................................... KC Registration .......................................................... Coat Colour: .......................................... Sample: [ ] EDTA Blood [ ] Buccal swabs [ ] Blood Card - Sample Date: .......................................... Sample label ......................................... Test (s) required (Provide both test number and test name from test list): Payment: [ ] I enclose a cheque / Postal order payable to LABOKLIN (UK) for the amount of £ .................... [ ] I made bank transfer to Laboklin UK: HSBC Sort Code: 40-31-30 Account number 41729624, Amount: £ ................ my reference is ................... [ ] I have already paid by paypal* the amount of £ ..................... my payment reference number is: ............................... * Paypal payment must be made to [email protected], please add 3% fees. [ ] I have already paid by credit / debit card the amount of £ ..................... my payment reference number is: .................................................... [ ] I would like to pay by credit / debit card (you may also ring 0161 2823066 to pay over the phone) the amount of : £...................................... Card Holder’s name: ............................................................... Card Number: ............................................................................... Card Expiry Date: ..................... Card Security (last 3 digits on the back of the card):......................... signature: .................................................... [ ] Cash £ ................................................ [ ] We are a UK veterinary surgery. Please invoice the practice / accounting office at the above address. * 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 to be recorded and published as part of the Kennel Club scheme and that these results will only be recorded and published by the KC if the result report includes the dog’s microchip or tattoo number along with either the dog’s registered name or registered number. Any test results that do not carry these identifying features will not be recorded by the Kennel Club. Signed ................................................................................................ (owner / agent) Date: ................................................................................................. I agree to allow my data to be transmitted to and processed by Laboklin UK in order to fulfil this contract. I have read the information and details on the use of the data and my rights at laboklin.co.uk/privacy Signed ................................................................................................ (owner / agent) Date: ................................................................................................. This form is downloadable from www.laboklin.co.uk ISO / DIN 17025 Accredited Laboratory THIS FORM IS ONLY VALID FOR SUBMISSIONS AT CRUFTS 2019 Dog Genetic Diseases Test No Disease or Condition Name Cost Incl. VAT [ ] 8258D Achromatopsia (Day Blindness) (ACHM) (German Shepherd, Labrador Retriever, Labrador crosses such as Labradoodle)) £ 43.20 [ ] 8038 Acral Mutilation Syndrome (AMS) (English Cocker Spaniel , English Springer Spaniel , German Shorthair Pointer , Cockapoo (English) , English Pointer and French £ 43.20 Spaniel ) Official UK Kennel Club DNA testing scheme in English Cocker Spaniel and English Springer Spaniel. [ ] 8595 Acute Respiratory Distress Syndrome ( ARDS ) (Dalmatian ) £ 43.20 [ ] 8313 Alaskan Husky Encephalopathy (AHE) (Alaskan Husky) £ 43.20 [ ] 8223D Alaskan Malamute Polyneuropathy (AMPN) (Alaskan Malamute) Official UK Kennel Club DNA testing scheme in Alaskan Malamute. £ 43.20 [ ] 8601 Alexander Disease ( AxD ) (Labrador Retriever) £ 43.20 [ ] 8303 Amelogenesis Imperfecta (AI) / Familial Enamel Hypoplasia (FEH) (Italian Greyhound, Samoyed) £ 43.20 [ ] 8207 Bardet Biedl Syndrome (BBS) (Hungarian Puli (Hungarian water dog)) £ 43.20 [ ] 8219D Brachyury (Bobtail Gene / Short Tail) ( Australian Shepherd, Australian Stumpy tail cattle Dog, Austrian Pinscher, Bourbonnais Pointer, Brazilian Terrier, Bouvier £ 43.20 des Ardennes, Brittany Spaniel, Croatian Sheepdog, Danish Farm Dog, Jack Russell Terrier, Karelian Bear Dog, Mudi, Polish Lowland sheepdog, Pyrenean Shepherd, Savoy Sheepdog, Schipperke, Spanish Waterdog, Swedish Farm Dog, Swedish Vallhund, Welsh Corgi ) . The Test is NOT SUITABLE for the following breeds: Boston Terrier,
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