Submission form Genetics Dog/Cat Customer-No. / Barcode Business Hours: Mo - Fr: 8:00 - 19:00 h, Sa: 9:00 - 13:00 h Clinic address: Owners address: (stamp or block letters) (block letters only, please) Name: Invoice to: Veterinarian Owner _______________________________________ First name:_______________________________________ Street: _______________________________________ _________________________ (owners signature for direct Zipcode/city: _______________________________________ invoicing) Fax/e-mail:_______________________________________ Fax/e-mail: _________________________________________________ Tel.: _______________________________________ Notification: Courier 8105 E-mail Fax Mail Report copy to owner Certificate 7,15 € I have checked the animals identity and assure that samples are taken from the animals mentioned below. Name: ____________________________________________________- Signature / Stamp_________________________________________________ veterinarian: Patient-ID:_________________________________________ Date of sampling: ______________________________________ Please note: Indication of breed is absolutely required! Animal 1 (MUST BE FILLED OUT - if known, in Capital letters, please) Sample: 0,5 ml EDTA-blood Name: ___________________________________________________________________ Date of birth: _______________________________________ Breed: ___________________________________________________________________ Coat colour: swab blood card Sex: F Pedigree-No.: ___________________________________________________________________ Tatoo-No.: M _______________________________________ _______________________________________ Microchip-No.: ___________________________________________________________________ Sample label: _____________________________________ Animal 2 (MUST BE FILLED OUT - if known, in Capital letters, please) Sample: 0,5 ml EDTA-blood Name: ___________________________________________________________________ Date of birth: _______________________________________ Breed: ___________________________________________________________________ Coat colour: swab blood card Sex: F Pedigree-No.: ___________________________________________________________________ Tatoo-No.: M _______________________________________ _______________________________________ Microchip-No.: ___________________________________________________________________ Sample label: _____________________________________ Animal 3 (MUST BE FILLED OUT - if known, in Capital letters, please) Sample: 0,5 ml EDTA-blood Name: ___________________________________________________________________ Date of birth: _______________________________________ Breed: ___________________________________________________________________ Coat colour: swab blood card Sex: F Pedigree-No.: ___________________________________________________________________ Tatoo-No.: M _______________________________________ _______________________________________ Microchip-No.: ___________________________________________________________________ Sample label: _____________________________________ Credit card Visa Mastercard Total amount:________________________________________________________________ Invoice-No.: _________________________________________________ Credit card No.: ________________________________________________________________ Exp. _________________________________________________ date: Cardholders name: ______________________________________________________________ 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" D000150050103D 000150050103 Dog Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs) 8193 Arrhythmogenic Right Ventricular Cardiomyopathy* (ARVC) (Boxer) 8219 8062 Canine Leucocyte Adhesion Deficiency (CLAD) (Irish Red and White Setter, Irish Setter) 8120 Collie Eye Anomaly* (CEA) OPTIGEN (Australian Shepherd, Bearded Collie, Border Collie, Boykin Spaniel, Hokkaido, Lancashire Heeler, Longhaired Whippet, Nova Scotia Duck Tolling Retriever, Rough,Smooth Collie, Shetland Sheepdog) 8434 Congenital Hypothyroidism with goiter (CHG) (Spanish Waterdog) 8000 Copper Toxicosis (CT) (Bedlington Terrier) 8013 Cystinuria (Newfoundland, Landseer) 8158 Degenerative Myelopathy (DM) (All breeds) 8194 Dilated Cardiomyopathy* (DCM) (Doberman) 8406 8407 Dry Eye Curly Coat Syndrome (CCS) 8069 8151 Factor VII Deficiency Familial Nephropathy* (FN) Familial Nephropathy (FN) 8011 Glycogen Storage Disease (GSDIIIa) (Curly Coated Retriever) 8066 GM1-Gangliosidosis Grey Collie Syndrome (Canine Cyclic Neutropenia) 8452 (Beagle) Retinal Atrophy 8135 8451 Hemophilia B (Factor IX deficiency) Hereditary Cataract (HSF4) Hereditary Myopathy (CNM) (American Cocker Spaniel, American Eskimo Dog, Australian Cattle Dog, Australian Shepherd, Australian Stumpy Tail Cattle Dog, Chesapeake Bay Retriever, Hereditary Nasal Parakeratosis (HNPK)* Chinese Crested, Cockapoo, Dwarf Poodle, English Cocker Spaniel, Entlebucher Mountaindog, Finnish Lapphund, Golden Doodle, Golden Retriever, Kuvasz, Lapponian Herder, Labrador Retriever, Labradoodle, Markiesje, Nova Scotia Duck Tolling Retriever, Norwegian Elkhound, Portuguese Waterdog, Swedish Lapphund, Toy Poodle, Spanish Water Dog, Silky Terrier, Yorkshire Terrier) Hereditary Necrotizing Myelopathy (HNM)* Hereditary Neuropathy (GHN) Hyperuricosuria (SLC) 8002 (All breeds) 8437 8002 Junctional Epidermolysis Bullosa (JEB) Juvenile Dilatative Cardiomyopathy (JDCM)* Juvenile Epilepsy* (Lagotto Romagnolo) 8197 rcd 2-PRA* OPTIGEN (Collie) 8002 (Portuguese Waterdog) 8459 rcd 1a-PRA (Sloughi) 8153 (German Shorthaired Pointer) 8204 rcd 1-PRA (Irish Setter, Irish Red and White Setter) Ichthyosis (Golden Retriever) 8198 GR_PRA1 (Golden Retriever) (Greyhound) 8154 Generalized PRA prcd-PRA 8094 performed by OPTIGEN* 8127 performed by partnerlab* (Dutch Kooiker) 8179 Dominant Form of PRA (Schapendoes) 8200 (Labrador Retriever) 8421 crd-PRA (Standard Wirehaired Dachshund) 8002 (Labrador Retriever) 8421 Primary Open Angle Glaucoma (POAG) (Bull Mastiff, English Mastiff) Hemophilia A (Factor VIII deficiency) (Australian Shepherd, Wäller) 8073 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 Terrier, Toy Fox Terrier, Volpino Italiano, Welsh Terrier) (Rhodesian Ridgeback) 8157 Polyneuropathie (AMPN) (Alaskan Malamute) 8226 (Bichon Havanese) 8221 Phosphofructokinase Deficiency (PFKD) (American Cocker Spaniel, English Springer Spaniel, Whippet, Wachtelhund) 8479 (Collie) 8232 Osteogenesis imperfecta (Shorthaired, Wirehaired Dachshund) 8017 (Husky, Portuguese Waterdog) 8098 Night Blindness (CSNB) (Briard) 8215 (Cairn Terrier, West Highland White Terrier) 8156 Neuronal Ceroid Lipofuscinosis (NCL) (American Bulldog, Australian Shepherd, Border Collie, Dachshund, English Setter, Tibet Terrier) Fucosidosis Globoid Cell Leucodystrophy / Krabbe-disease Neonatal Encephalopathy (NEWS) (Standard Poodle) (English Springer Spaniel) 8007 Neonatal Cerebellar Abiotrophy (NCCD) (Beagle) (English Springer Spaniel, Samoyed) 8016 Necrotizing Meningoencephalitis (MNE) (Pug) 8457 (English Cocker Spaniel) 8192 Narcolepsy (Doberman Pinscher, Labrador Retriever) 8429 (Airedale Terrier, Alaskan Klee Kai, Beagle, Giant Schnauzer, Scottish Deerhound) 8131 Myotonia Congenita (Miniature Schnauzer) 8067 8075 (Boykin Spaniel, Chesapeake Bay Retriever, Curly Coated Retriever, German Wirehaired Pointer, Labrador Retriever, Pembroke Welsh Corgi) Myostation mutation("Bully-Gen") (Whippet) 8022 Dry Eye Curly Coat Syndrome (CCS) + Episodic Falling Exercise Induced Collapse (EIC) Musladin-Lueke Syndrome (MLS) (Beagle) 8220 (Cavalier King Charles Spaniel) (Cavalier King Charles Spaniel) 8152 Muscular Dystrophy (Cavalier King Charles Spaniel, Golden Retriever) 8411 8155 Episodic Falling (EF) Mucopolysaccharidosis Type VII (MPS) (German Shepherd) 8068 (Cavalier King Charles Spaniel) 8202 MDR1 Gene Defect* (Ivermectin Sensitivity) (American White Shepherd, Australian Shepherd, Bobtail, Border Collie, Elo, German Shepherd, Longhaired Whippet, Mc Nab, Rough,- Smooth Collie, Shetland Sheepdog, Silken Windhound, Waeller, Weißer Schweizer Schäferhund) Brachyury (Breeds upon request) 8012 Malignant Hyperthermia (MH) (All breeds) 8032 rcd 3-PRA (Welsh Corgi) 8435 rcd 4-PRA (Gordon Setter, Irish Setter, Tibet Terrier) Juvenile Renale Dysplasia (JRD)* (Breeds upon request) 8125 L-2-Hydroxyglutaric Aciduria (L-2-HGA) (Staffordshire Bull Terrier) 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. D000000000001D 000000000001 Dog Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs) 8104 Pyruvat Dehydrogenase Phosphatase 1 Deficiency von-Willebrand-Disease (Clumber, Sussex-Spaniel) 8210 8015 von-Willebrand-Disease (Dutch Kooiker) Pyruvatkinase Deficiency (PK Deficiency) (Basenji, Beagle, Labrador Retriever, Pug, Westhighland White Terrier) 8119 8150 (Labrador Retriever, Samoyed) 8191 Startle Disease (Irish Wolfhound) von-Willebrand Disease Type 1 (Bernese Mountain Dog, Coton de Tulear, Doberman, Drentsche Patrijshond, German Pinscher, Labradoodle, Manchester Terrier, Kerry Blue Terrier, Papillon, Pembroke Welsh Corgi, Poodle, Stabyhound) Retinal Dysplasia* (OSD) OPTIGEN 8014 von-Willebrand Disease Type 2 (German Shorthaired Pointer, German Wirehaired Pointer) 8143 Trapped Neutrophil Syndrome (TNS) (Border Collie) 8233 von-Willebrand Disease Type 3 (Scotch Terrier, Sheltie) 8456 Dwarfism (Skeletal Dysplasia 2) (Labrador Retriever) 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) 8144 8023 8196 A-Locus (Agouti) B-Locus (Coat Colour Brown) 8195 8124 8405 Curly Furnishing Coat Length Improper Coat (Portuguese Waterdog) 8136 8018 8458 D-Locus (Dilution) E-Locus (Coat Colours Yellow, Lemon, Red, Cream, Apricot) EG-locus domino/grizzle 8145 8185 8180 (Afghan Hound, Saluki) 8146 EM-Locus (Melanistic Mask Allele) K-Locus K-Lokus* (brindle) Sable* (English Cocker Spaniel) 8438 S-Locus* DNA-Profile / Parentage** (Sample Material: 0,5 - 1 ml EDTA-blood) 8109 Parentage verification 8212 Likelihood ratio calculation (incl. DNA-Profile) (Breeds upon request) 8107 DNA-Profile (each parent) (Identity confirmation) 8211 Breed Analysis (DNA-Profile + assignment) (Breeds upon request) 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. D000000000002D 000000000002 Cat Hereditary Diseases (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs) 8002 8453 Gangliosidosis (GM 1/GM 2) (Korat, Oriental Shorthair, Siamese) 8149 Gangliosidosis (GM2) (Burmese) 8113 Polycystic Kidney Disease (PKD) (Persian and related breeds) Glycogen Storage Disease (GSD) Type IV 8117 (Norwegian Forest Cat) 8465 Hypokalemia* (Burmese) 8013 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) 8080 8015 Hypertrophic Cardiomyopathy (HCM) Mutation 1 Meurs (G --> C)(Maine Coon) 8116 Pyruvatkinase Deficiency (PK) (Abyssinian, Bengal, Domestic Shorthair and Longhair, Egyptian Mau, La Perm, Occicat, Maine Coon, Norwegian Forest, Savannah, Siberian, Singapura, Somali) Hypertrophic Cardiomyopathy (HCM) 8123 (Ragdoll) Feline Spinal Muscular Atrophy (SMA) (Maine Coon) Coat Colours / Coat Length (Sample Material: 0,5 - 1 ml EDTA-blood, Buccal Swabs) 8090 8170 Coat Colour Variant Agouti (All breeds) 8086 Coat Colour Variant Burmese (All breeds) 8085 Coat Colour Chocolate (All breeds) 8083 Coat Colour Variant Siamese (Point) (All breeds except Bengal) 8099 Coat Colour Amber (Norwegian Forest Cat) 8084 Coat Colour Cinnamon (All breeds) 8147 Coat Colour Variant Dilution (All breeds) Coat Length (All breeds) Blood Group Testing 8121 618 Genetical Blood Group Testing (All breeds except Turkish Angora, Ragdoll, Sibirian, Neva Masquerade, European Shorthair) Serological Blood Group Testing (only EDTA Blood) (All breeds) 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) 8109 8211 8107 Parentage verification DNA-Profile (each parent) Breed Analysis (DNA-Profile + assignment) (Breeds upon request) 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 000000000003 55 Cytobrushes (DNA-tests) 64 Submission forms - GENETICS 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
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