CANINE DNA RESEARCH Breed _________________________
Individual Dog Information Litter ID code:___________________
Registered Name _________________________________ Call name _________________
AKC# ________________ Birth Date _____________ Male / Female - - Intact / Neutered
Sample Submission Date: ____________________ Color __________________________
Sample submitted for which research project? _____________________________________________
Owner: name ___________________________ Alternate _______________________
address _________________________ Contact ________________________
phone (day) ______________________ ________________________
phone (eve) ______________________ ________________________
fax __________________________ ________________________
e-mail ___________________________ ________________________
Does this dog exhibit any of the following conditions? (Please attach history for any Yes answer)
Y - N Allergies Y - N Digestive difficulties
Y - N Arthritis Y - N Heart Problems
Y - N Autoimmune Disorders Y - N Hernia (where? ____________________ )
Y - N Bite or Tooth Abnormalities Y - N Reproductive Problems
Y - N Cancer / Tumors Y - N Seizures
Y - N Cataracts / Vision Problems Y - N Skin / Coat Problems
Y - N Deafness / Hearing Impaired Y - N Skeletal Abnormalities (Hip Dysplasia, etc.)
other (please list): Y - N Temperament Problems (shy, aggressive, etc.)
Testing done on this dog:
OFA/PennHip Y - N age at test: __________ result:________ #__________
CERF Y - N age last tested:_______ result:________ #__________
Thyroid Y - N age last tested:_______ result:________
other (please list):
Other Comments / Questions / Concerns?
Please circle your response to the following;
- I am / am not willing to provide additional blood samples if needed for research.
- I will / will not consider donation of a tissue sample (spleen, kidney, or liver) upon the death of this dog, and will discuss this decision with my veterinarian so that a notation is placed in my file.
I submit this sample and pedigree for the purpose of DNA research; I understand that the identity of dogs and owners participating in the research will not be revealed; and I have supplied complete and accurate information, to the best of my knowledge.
Signed: ______________________________________ date __________________