PK DEFICIENCY INFORMATION

0 Owner Name _____________________________________________________

0 Breeder Street _____________________________________________________

0 Veterinarian City __________________________ State ______ Zip ___________

Phone _____________________ Fax ________________________________________

Email _________________________________________________________________

Date of sample collection ____________________ Date of Birth _______________________

Animal's Name ____________________________ Breed ________________________

AKC#/CFA# or Other registration # __________________________________________

Sex: 0Female 0 Male

Neutered: 0Yes 0 No

Sire/Tom ________________________________________ AKC#/CFA# _______________________

Dam/Queen _________________________________ AKC#/CFA# ____________________

Reason for Testing (select all that apply)

0 General Genetic Screening 0 Showing

0 Suspicious Clinical Signs 0 Breeding

0 Puppy or Kitten (at least four weeks old)

0 Relative known to be affected (please state who) ________________________

0 Other (explain) ___________________________________________________

Tests to be conducted

0 PK DNA screening only $75

0 Blood Typing only $15

0 Both PK DNA screening and Blood Typing $90

Please send the sample, form and check payable to "Trustees, University of Pennsylvania/Giger" via two-day priority delivery mail to:


Dr. Urs Giger/PK Deficiency


Veterinary Hospital Room 4006


University of Pennsylvania


3850 Spruce Street


Philadelphia, PA 19104-6010


Phone: (215) 898-3375


Fax: (215) 573-2162


Email: penngen@vet.upenn.edu


www.vet.upenn.edu/penngen



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