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Genetics Dog Submission Form

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Genetics Dog Submission Form + Invoice to owner Invoic Submission form Customer-No. / Barcode LABOR FÜR KLINISCHE DIAGNOSTIK GMBH & CO. KG Genetics Dog PB 1810 DE-97668 Bad Kissingen Tel +49 971 72020 Fax +49 971 68546 Business Hours: Mon - Fri: 9:00 - 18:00 h, Sat: 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/email: _________________________________________________ Fax/email:_________________________________________ Date/Signature:_______________________________________________________________ Courier Tel.: _________________________________________ Notification: Email Fax Mail Report copy to owner 8105 Certificate 9.00 € 1) The sample has to be collected by a veterinarian or an impartial person. 2) The identity of the animal must be specified by Microchip-No., Tattoo-No. and/or Pedigree-No. 3) Certificates are included in the services of DNA-profile and parentage testing; No certificates are provided for partnerlaboratory services. I have checked the animals identity and confirm that samples are taken from the animals listed below. Name ___________________________________________________veterinarian: ____________Signature / Stamp___________________________________________________ veterinarian: ____________ Patient-ID:_______________________________________________________________Date of sampling:_______________________________________________________________ Please note: Indication of breed is mandatory! (Please complete using capital letters) Animal 1 (previous result-number, if known: __ __ __ __ - __ - __ __ __ __ __ ) Sample: 0.5 - 1 ml EDTA-blood 2x buccal swab blood card Sex: female male Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.: Sample_______________________________________________ label: e to owner + Invoice Animal 2 (previous result-number, if known: __ __ __ __ - __ - __ __ __ __ __ ) Sample: 0.5 - 1 ml EDTA-blood 2x buccal swab blood card Sex: female male Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.: Sample_______________________________________________ label: Animal 3 (previous result-number, if known: __ __ __ __ - __ - __ __ __ __ __ ) Sample: 0.5 - 1 ml EDTA-blood 2x buccal swab blood card Sex: female male Name: _______________________________________________________________ Date of_______________________________________________ birth: Breed: _______________________________________________________________ Coat colour:_______________________________________________ Pedigree-No.:_______________________________________________________________ Tattoo-No.:_______________________________________________ Microchip-No.: Sample_______________________________________________ label: 010110110060 Hereditary diseases € € 8552 8202 Acatalasemia 59.50 Episodic falling (EF) 59.50 (Beagle) (Cavalier King Charles Spaniel) 8166 8152 Achromatopsia (day blindness) (ACHM) 59.50 Exercise induced collapse (EIC) 77.50 (German Shepherd, Labrador Retriever) (Boykin Spaniel, Chesapeake Bay Retriever, Clumber Spaniel, Curly Coated 8595 59.50 Retriever, Labrador Retriever, Old English Sheepdog, Pembroke Welsh Corgi, Acute respiratory distress syndrome (ARDS) Wirehaired Pointer) (Dalmatian) 8259 8151 Adult onset neuropathy * ̓ ** (AON) 77.50 Faktor VII deficiency 59.50 (English Cocker Spaniel, Field Spaniel) (Airedale Terrier, Alaskan Klee Kai, Beagle, Finnish Hound, Giant Schnauzer, 8313 Alaskan Husky encephalopathy (AHE) 59.50 Scottish Deerhound, Welsh Springer Spaniel) 8131 (Husky) Familial nephropathy (FN)* 77.50 8479 Alaskan Malamute polyneuropathy (AMPN) 59.50 (English Cocker Spaniel, Welsh Springer Spaniel) 8192 (Alaskan Malamute) Familial nephropathy (FN) 59.50 8601 Alexander disease (AxD) 59.50 (English Springer Spaniel, Samoyed) 8272 (Labrador Retriever) Fanconi syndrome 59.50 8303 Amelogenesis imperfecta (AI) 59.50 (Basenji) 8467 (Italian Greyhound) Finnish Hound ataxia (FHA) 59.50 8207 Bardet-Biedl syndrome (BBS) 59.50 (Finnish Hound, Norrbottenspitz) 8016 (Puli) Fucosidosis 59.50 8219 Brachyuria (stumpy tail) 59.50 (English Springer Spaniel) 8323 (Australian Shepherd, Australian Stumpy Tail Cattle Dog, Austrian Pinscher, Gallbladder mucoceles 59.50 Bourbonnais Pointer, Bouvier des Ardennes, Brazilian Terrier, Brittany Spaniel, (American Cocker Spaniel, Cairn Terrier, English Cocker Spaniel, Pomeranian, Croatian Sheepdog, Danish/Swedish Farmdog, Jack Russell Terrier, Karelian Shetland Sheepdog) Bear Dog, Mudi, Polish Lowland Sheepdog, Pyrenean Shepherd, Savoy 8077 Sheepdog, Schipperke, Spanish Waterdog, Swedish Vallhund, Welsh Corgi) Glanzmann Thrombastenia (GT) 59.50 8184 C3-Deficiency (C3) 59.50 (Pyrenean Mountain Dog) 8007 (Brittany Spaniel) Globoid cell leukodystrophy / Krabbe-disease 59.50 8012 Canine leukozyte adhesion deficiency (CLAD) 59.50 (Cairn Terrier, Irish Setter, West Highland White Terrier) 8322 (Irish Setter, Irish Red and White Setter) Glycogen storage disease GSD Ia 59.50 8330 Canine multi-focal retinopathy (CMR1/2/3) 77.50 (Maltese) 8513 (American Bulldog, Australian Shepherd, Boerboel, Bullmastiff, Cane Corso, Glycogen storage disease GSD II (Pompe disease) 59.50 Coton de Tulear, Dogo Canario, Dogue de Bordeaux, English Bulldog, English (Finnish Lapphund, Lapponian Herder, Swedish Lapphund) Mastiff, Finnish Lapphund, French Bulldog, Lapponian Herder, 8156 Pyrenean Mountain Dog, Swedish Lapphund) Glycogen storage disease GSD IIIa 59.50 (Curly Coated Retriever) 8575 8066 e to owner + + + Invoice to owner + + + Invoice to owner + + + Invoice to owner + + + e to owner + Invoice Canine multiple system degeneration (CMSD) 59.50 GM1-Gangliosidosis (GM1) 59.50 (Chinese Crested, Kerry Blue Terrier) (Portuguese Waterdog, Shiba Inu, Siberian Husky) 8073 8208 Centronuclear myopathy (CNM) 59.50 GM2-Gangliosidosis (GM2) 59.50 (Great Dane, Labrador Retriever) (Japanese Chin, Toy Poodle) 8314 8098 Cerebral dysfunction (CDFS) 59.50 Grey Collie syndrome (GCS) 59.50 (Stabyhoun) (Canine cyclic neutropenia) 8316 Chonrodysplasia (dwarfism) 59.50 (Collie) 8232 (Chinook, Karelian Bear Dog, Norwegian Elkhound) Haemophilia A (factor VIII - deficiency) 77.50 8326 Cleft lip/palate and syndactyly (CLPS) 59.50 (Boxer, German Shepherd, Havanese, Old English Sheepdog) 8221 (Nova Scotia Duck Tolling Retriever) Haemophilia B (factor IX - deficiency) 77.50 8120 Collie eye anomaly (CEA) * ̓ ** Optigen 157.00 (Lhasa Apso, Rhodesian Ridgeback) 8304 8319 Collie eye anomaly (CEA)* partner laboratory 59.50 Haemorrhagic diathesis (Scott syndrome) 59.50 (Australian Shepherd, Bearded Collie, Border Collie, Boykin Spaniel, Hokkaido, (German Shepherd) 8449 Lancashire Heeler, Longhaired Wippet, Nova Scotia Duck Tolling Retriever, Hereditary ataxia (HA) 59.50 Rough/Smooth Collie, Shetland Sheepdog, Silken Windhound) (Gordon Setter, Old English Sheepdog) 8256 8157 Cone degeneration (CD) * ̓ ** Optigen 167.00 Hereditary cataract (HSF4) 59.50 (Alaskan Malamute, Australian Shepherd, German Shorthaired Pointer) (Australian Shepherd, Wäller) 8434 8576 Congenital hypothyroidism with goiter (CHG) 59.50 Hereditary cataract (HSF4)* 59.50 (Fox Terrier, French Bulldog, Rat Terrier, Spanish Waterdog, Tenterfield Terrier) (Boston Terrier, French Bulldog, Staffordshire Bull Terrier) 8317 8672 Congenital ichthyosis 59.50 Hereditary nasal parakeratosis (HNPK) 59.50 (Great Dane) (Greyhound) 8206 8421 Congenital myasthenic syndrome (CMS) 59.50 Hereditary nasal parakeratosis (HNPK) 103.00 (Golden Retriever, Jack Russell Terrier, Labrador Retriever, Old Danish (Labrador Retriever) 8179 Pointing Dog, Parson Russell Terrier) Hereditary neuropathy (GHN) 59.50 8011 Congenital stationary night blindness (CSNB) 59.50 (Greyhound) 8154 (Briard) Hyperurikosuria (SLC) 59.50 8034 Copper storage disease - Copper toxicosis 59.50 (all breeds) 8443 (Bedlington Terrier) Hypomyelination / Shaking puppy syndrome (SPS) 59.50 8348 Craniomandibular osteopathy (CMO) 59.50 (English Springer Spaniel, Weimaraner) 8555 (Cairn Terrier, Scottish Terrier, West Highland White Terrier) Ichthyosis 59.50 8013 Cystinuria 59.50 (American Bulldog) 8481 (Australian Cattle Dog, Continental Bulldog, English Bulldog, French Bulldog, Ichthyosis* 59.50 Labrador Retriever, Landseer, Newfoundland, Mastiff, Miniature Pinscher, Olde (Golden
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