Submission form Genetics Dog/Cat
Business Hours: Mo - Fr: 8:00 - 19:00 h, Sa: 9:00 - 13:00 h
_________________________________________________
I have checked the animals identity and assure that samples are taken from the animals mentioned below.
________________________________________________-
_ :__________________________________________-
Patient-ID:_________________________________________
Please note: Indication of breed is absolutely required! Animal 1 (MUST BE FILLED OUT - if known, in Capital letters, please)
___________________________________________________________________
_________________________________________
________________________________________________________________ C
_________________________________________
Pedigree-No.: __________________________________________________________________
_________________________________________
Microchip-No.: ___________________________________________________________________
Animal 2 (MUST BE FILLED OUT - if known, in Capital letters, please)
___________________________________________________________________
_________________________________________
___________________________________________________________________
_________________________________________
Pedigree-No.: ________________________________________________________________ T
_________________________________________
Microchip-No.: ________________________________________________________________ S
Animal 3 (MUST BE FILLED OUT - if known, in Capital letters, please)
________________________________________________________________ D
_________________________________________
________________________________________________________________ C
_________________________________________
Pedigree-No.: __________________________________________________________________
_________________________________________
Microchip-No.: ________________________________________________________________ S
Credit card
Total amount:________________________________________________________________
______________________________________________
_______________________________________________________________
_ :_______________________________________________
_ :_____________________________________________________________ Cardholders signature:
_________________________________________
For accepting credit card we charge EUR 2,10 plus VAT. Please note: The genetic tests for horses can be found on lab order "Horse"
Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs)
Arrhythmogenic Right Ventricular Cardiomyopathy* Malignant Hyperthermia (MH) (All breeds) (ARVC) (Boxer)
8032 MDR1 Gene Defect* (Ivermectin Sensitivity)
(American White Shepherd, Australian Shepherd, Bobtail, Border Collie, Elo, German
Brachyury
Shepherd, Longhaired Whippet, Mc Nab, Rough,- Smooth Collie, Shetland Sheepdog,
Silken Windhound, Waeller, Weißer Schweizer Schäferhund)
8012 Canine Leucocyte Adhesion Deficiency (CLAD)
(Irish Red and White Setter, Irish Setter)
8069 Mucopolysaccharidosis Type VII (MPS) Collie Eye Anomaly* (CEA) OPTIGEN (Australian Shepherd, Bearded Collie, Border Collie, Boykin Spaniel, Hokkaido,
8068 Muscular Dystrophy
Lancashire Heeler, Longhaired Whippet, Nova Scotia Duck Tolling Retriever, Rough,-
(Cavalier King Charles Spaniel, Golden Retriever)
8411 Musladin-Lueke Syndrome (MLS) Congenital Hypothyroidism with goiter (CHG) (Spanish Waterdog)
8220 Myostation mutation("Bully-Gen") Copper Toxicosis (CT) Myotonia Congenita Cystinuria Narcolepsy Degenerative Myelopathy (DM) (All breeds)
8429 Necrotizing Meningoencephalitis (MNE) Dilated Cardiomyopathy* (DCM) (Doberman)
8457 Neonatal Cerebellar Abiotrophy (NCCD)
8406 Dry Eye Curly Coat Syndrome (CCS)
8155 Neonatal Encephalopathy (NEWS)
8407 Dry Eye Curly Coat Syndrome (CCS) + Episodic Falling Neuronal Ceroid Lipofuscinosis (NCL)
(American Bulldog, Australian Shepherd, Border Collie, Dachshund, English Setter,
Episodic Falling (EF) (Cavalier King Charles Spaniel)
8011 Night Blindness (CSNB) Exercise Induced Collapse (EIC) (Boykin Spaniel, Chesapeake Bay Retriever, Curly Coated Retriever, German
8215 Osteogenesis imperfecta
Wirehaired Pointer, Labrador Retriever, Pembroke Welsh Corgi)
Factor VII Deficiency Phosphofructokinase Deficiency (PFKD)
(Airedale Terrier, Alaskan Klee Kai, Beagle, Giant Schnauzer, Scottish Deerhound)
(American Cocker Spaniel, English Springer Spaniel, Whippet, Wachtelhund)
Familial Nephropathy* (FN) Polyneuropathie (AMPN) Familial Nephropathy (FN) Primary Lens Luxation (PLL)
(Chinese Crested, Jack Russell Terrier, Jagd Terrier, Lancashire Heeler, Miniature Bull
Terrier, Parson Russell Terrier, Patterdale Terrier, Rat Terrier, Sealyham Terrier, Tibet
Fucosidosis
Terrier, Toy Fox Terrier, Volpino Italiano, Welsh Terrier)
Globoid Cell Leucodystrophy / Krabbe-disease Primary Open Angle Glaucoma (POAG)
(Cairn Terrier, West Highland White Terrier)
8156 Glycogen Storage Disease (GSDIIIa) GM1-Gangliosidosis Grey Collie Syndrome (Canine Cyclic Neutropenia) Dominant Form of PRA Hemophilia A (Factor VIII deficiency) Generalized PRA Hemophilia B (Factor IX deficiency)
8157 Hereditary Cataract (HSF4) prcd-PRA
8094 performed by OPTIGEN* Hereditary Myopathy (CNM) performed by partnerlab*
(American Cocker Spaniel, American Eskimo Dog, Australian Cattle Dog, Australian
Shepherd, Australian Stumpy Tail Cattle Dog, Chesapeake Bay Retriever,
Hereditary Nasal Parakeratosis (HNPK)* (Labrador Retriever)
Chinese Crested, Cockapoo, Dwarf Poodle, English Cocker Spaniel, Entlebucher
Mountaindog, Finnish Lapphund, Golden Doodle, Golden Retriever, Kuvasz,
Hereditary Necrotizing Myelopathy (HNM)*
Lapponian Herder, Labrador Retriever, Labradoodle, Markiesje, Nova Scotia Duck
Norwegian Elkhound, Portuguese Waterdog, Swedish Lapphund, Toy Poodle, Spanish
Hereditary Neuropathy (GHN)
Water Dog, Silky Terrier, Yorkshire Terrier)
Hyperuricosuria (SLC) rcd 1-PRA
(Irish Setter, Irish Red and White Setter)
Ichthyosis rcd 1a-PRA Junctional Epidermolysis Bullosa (JEB) rcd 2-PRA* OPTIGEN Juvenile Dilatative Cardiomyopathy (JDCM)* rcd 3-PRA Juvenile Epilepsy* rcd 4-PRA
(Gordon Setter, Irish Setter, Tibet Terrier)
8197 Juvenile Renale Dysplasia (JRD)*
8125 L-2-Hydroxyglutaric Aciduria (L-2-HGA) In order to allow the breeding club discount please enclose a breeding club membership confirmation to each sample submission. The invoice can not be altered subsequently.
Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs)
8104 Pyruvat Dehydrogenase Phosphatase 1 Deficiency
8210 von-Willebrand-Disease Pyruvatkinase Deficiency (PK Deficiency) (Basenji, Beagle, Labrador Retriever, Pug, Westhighland White Terrier)
8119 von-Willebrand Disease Type 1
(Bernese Mountain Dog, Coton de Tulear, Doberman, Drentsche Patrijshond, German
Retinal Dysplasia* (OSD) OPTIGEN
Pinscher, Labradoodle, Manchester Terrier, Kerry Blue Terrier, Papillon, Pembroke
8191 Startle Disease
8014 von-Willebrand Disease Type 2
(German Shorthaired Pointer, German Wirehaired Pointer)
8143 Trapped Neutrophil Syndrome (TNS)
8233 von-Willebrand Disease Type 3
8456 Dwarfism (Skeletal Dysplasia 2)
8142 Dwarfism
(Czechoslovakian Wolfdog, German Shepherd, Saarloos Wolfdog)
Coat Colours / Coat Length (Breeds upon request) (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs)
A-Locus (Agouti) Furnishing B-Locus (Coat Colour Brown) Coat Length Improper Coat (Portuguese Waterdog)
8136 D-Locus (Dilution)
8145 K-Locus
8018 E-Locus (Coat Colours Yellow, Lemon, Red, Cream, Apricot) K-Lokus* (brindle) EG-locus domino/grizzle EM-Locus (Melanistic Mask Allele) S-Locus*
DNA-Profile / Parentage** (Sample Material: 0,5 - 1 ml EDTA-blood)
Parentage verification Likelihood ratio calculation (incl. DNA-Profile) (Breeds upon request) DNA-Profile (each parent) Breed Analysis (DNA-Profile + assignment) For parentage evaluation DNA profiles of each parent is needed. If only sample material from one parent is available we would like you to contact us prior to submitting the samples. In order to allow the breeding club discount please enclose a breeding club membership confirmation to each sample submission. The invoice can not be altered subsequently.
Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs)
Gangliosidosis (GM 1/GM 2) Hypokalemia* Gangliosidosis (GM2) Polycystic Kidney Disease (PKD) Glycogen Storage Disease (GSD) Type IV Progressive Retinal Atrophy (rdAc-PRA)
(Abyssinian, American Curl/Wirehair, Balinese, Bengal, Colorpoint Shorthair, Cornish
Rex, Javanese, Munchkin, Oriental Shorthair, Singapura, Siamese, Somali, Tonkinese)
Head Defect* (Burmese) Hypertrophic Cardiomyopathy (HCM) Pyruvatkinase Deficiency (PK)
Mutation 1 Meurs (G --> C)(Maine Coon)
(Abyssinian, Bengal, Domestic Shorthair and Longhair, Egyptian Mau, La Perm,
Occicat, Maine Coon, Norwegian Forest, Savannah, Siberian, Singapura, Somali)
Hypertrophic Cardiomyopathy (HCM) (Ragdoll)
8123 Feline Spinal Muscular Atrophy (SMA)
Coat Colours / Coat Length (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs)
Coat Colour Variant Agouti Coat Colour Amber Coat Colour Variant Burmese Coat Colour Chocolate Coat Colour Variant Siamese (Point) Coat Colour Cinnamon Coat Colour Variant Dilution Coat Length Genetical Blood Group Testing Serological Blood Group Testing
(All breeds except Turkish Angora, Ragdoll, Sibirian, Neva Masquerade, European
(only EDTA Blood) Serological evaluation of the blood group is needed to differentiate between groups A, B and AB. Prior to any blood transfusion both donor and recipient should be tested to avoid incompatibilities. SAMPLE MATERIAL: EDTA BLOOD Additional genetic testing of the blood group is helpful prior to selection of mating partners especially in case of the queen being group A or AB due to the fact that group A animals can carry and pass on the recessive b gene for group B. SAMPLE MATERIAL: EDTA BLOOD OR SWAB
DNA-Profile / Parentage** (Sample Material: 0,5 - 1 ml EDTA-blood)
Parentage verification DNA-Profile (each parent)
8211 Breed Analysis (DNA-Profile + assignment) For parentage evaluation DNA profiles of each parent is needed. If only sample material from one parent is available we would like you to contact us prior to submitting the samples. * Partnerlab **Additional Information DNA-Profile: Please send in samples from both parents even if only the parentage of the Father has to be verified. All animals with possible parenthood should be tested. Sampling should be performed by an officially appointed person if the result is going to be part of a legal issue.
1) The identity of the animal needs to be confirmed by a veterinarian (specified by Microchip-No, Tattoo-No.)
2) Certificates are not issued for partner laboratory services and genetic blood group testing of cats
3) Certificates are included in the services of DNA-profile and parentage testing
In order to allow the breeding club discount please enclose a breeding club member confirmation to each sample submission. The invoice will not be altered subsequently. Supply order:
D000000000003D Business Conditions:
All statements according to our conditions see (www.laboklin.com) / All terms and prices are subject to changes. * = partnerlab
015.005 12/11
Drug Information Sheet("Kusuri-no-Shiori") The information on this sheet is based on approvals granted by the Japanese regulatory authority. Approval details may vary by country. Medicines have adverse effects (risks) as wel as efficacies (benefits). It is important to minimize adverse effects and maximize efficacy. To obtain a better therapeutic response, patients should understand
PATIENT REGISTRATION elcome to Valley Dental Associates! Please complete all parts for our records. This information is strictly kept confidential . GETTING TO KNOW YOU CITY STATESINGLE MARRIED D