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 Showing0
Suspicious Clinical Signs 0 Breeding0
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 $750
Blood Typing only $150
Both PK DNA screening and Blood Typing $90Please send the sample, form and check payable to "Trustees, University of Pennsylvania/Giger" via two-day priority delivery mail to: