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Individual Dog Sample printable Form

CANINE DNA RESEARCH - Mastiff Epilepsy

Individual Dog Sample Submission Litter ID code: _____________________

Pick one: _____Blood   _____Tissue  _____Other  ________________________

Registered Name:_________________________________________________

 Call Name:______________________________________________________

AKC #________________Birth Date _____/_____/_____

Sex:  _____Male  _____Female

Sample Submission Date _____/_____/_____     Color:___________________

Owner:

Name:______________________________________________

Address:____________________________________________

Phone: _____________________day  ____________________evening

Fax: _______________________Email:__________________________

Does this dog exhibit any of the following conditions? (check all that apply)
(please attach history for all checked answers)

_____Allergies                                                             _____Digestive Difficulties
_____Arthritis                                                               _____Heart Problems
_____Autoimmune Disorders                                    _____Hernia (where?__________________
_____Bite/Tooth Abnormalities                                 _____Reproductive Problems
_____Cancer/Tumors                                                 _____Seizures
_____Cataracts/Vision Problems                             _____Skin/Coat Problems
_____Deafness/Hearing Impaired                            _____Temperament Problems (shy, aggressive...)
_____Skeletal Abnormalities (Hip Dysplasia, etc.)

Other:_____________________________________________________________

__________________________________________________________________

Testing done on this dog:

_____OFA - PennHip   age at test:_____   result: ___________________________

_____CERF                  age at test:_____  result: ____________________________

_____Thyroid                age at test_____  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 __________________

Please fill out, print, sign and date, and include with samples - one per dog.