Blood – Tissue – other _______________________

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 __________________