OPTIGEN - Printable Test Request Form

From: Subject: OPTIGEN - Printable Test Request Form Date: Mon, 15 Nov 2010 00:34:02 +0100 MIME-Version: 1.0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.optigen.com/opt9_printform.taf?lang=en X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5994 OPTIGEN - Printable Test Request Form

OPTIGEN Test Request Form

INSTRUCTIONS

This form is for submitting a test application to = OptiGen by=20 mail or fax. Feel free to duplicate and distribute this form to = others.=20 Please complete the form carefully and be sure to obtain the = required=20 signatures on it, then include one copy with payment in the sample = package=20 you send to OptiGen. Please read and print a copy of the Ship = Sample=20 instructions. Ship sample(s) to OptiGen, 767 Warren Road, Suite = 300,=20 Ithaca, NY 14850. If you want to submit your application = online,=20 please use our online=20 form.

_____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20

SECTION 1: OWNER INFORMATION

Name:

first________________________ initial ______=20 last_________________________________

Address:

City:

_____________________________

State/Province:

___________________________

Country:

_____________________________

Zip/Postal Code:

___________________________

Day Phone:

_____________________________

Evening Phone:

___________________________

Fax:

_____________________________

Email:

Co-Owner = Names:=20

first	________________________	initial	______	last	_________________________________
	________________________		______		_________________________________
	________________________		______		_________________________________ =20

SECTION 2: REPORTS

X Mail ALL reports are = mailed=20 to the owner. For additional rapid reports, select one: = Email = or =20 Fax =

Results will not be provided by phone. Test results will be=20 reported to genetic registries only according to policy determined = by each=20 parent club as described in the Registry Table.
To request = additional,=20 mailed reports to anyone other than the owner or qualified = registry,=20 please include an addressed envelope for each name and address (no = postage).

_____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20 _____________________________________________________________= _____________=20

SECTION 3: Dog Identification=20 (Indicate "N/A" if question not applicable) =
Breed:	_______________________________	Call Name: =	_____________________________
Registry:
Registered Name:
Registration #:
Birthdate: =	____/____/____ (mon/day/yr) Sex: ___Female ___Male
Tattoo/Chip#:	_________________________________ =20 CERF#/Other Eye Registry#: _________________
Registered Name of Sire: =
Registered Number of Sire: =
Registered Name of Dam: =
Registered Number of Dam: =

SECTION 4: Disease History
Date of last exam by an = ophthalmologist=20 (mon/day/yr): ____/____/_____ or = ___ never=20 examined
Eye Disease=20 History: ____ None=20 ____ Other	___ Canine Multifocal=20 Retinopathy ___ Cataracts ___ Collie Eye = Anomaly/Choroidal=20 Hypoplasia ___ Coloboma ___ Cone=20 Degeneration ___ Cone-Rod Dystrophy ___ Congenital = Stationary Night Blindness ___ Primary Lens=20 Luxation ___ Progressive Retinal = Atrophy ___ Retinal=20 Dysplasia/Retinopathy ___ Retinal Folds	Comment: ___________________________________=20 ___________________________________
Other Disease:=20 ___ None=20 ___ Other	___ Canine Leukocyte Adhesion=20 = Deficiency ___ Cystinuria ___ Epilepsy ___ Famili= al=20 Nephropathy ___ Improper Coat ___ Myotonia=20 Congenita	___ Narcolepsy ___ Neuronal Ceroid=20 Lipofuscinosis ___ OculoSkeletal=20 Dysplasia ___ Phosphofructokinase = Deficiency ___ Pyruvate=20 Kinase Deficiency ___ Rage

_____________________________________________________________= ________=20 _____________________________________________________________= ________=20 _____________________________________________________________= ________=20

If available, please provide information on the = examining=20 ophthalmologist or veterinary specialist.
Name:
Address:
City:	_____________________________	State/Province:	_____________________________
Zip/Postal Code:	_____________________________	Country:	_____________________________
Phone:	_____________________________	Fax:	_____________________________
Email:

SECTION 5: SAMPLE INFORMATION
___ Blood sample is already at OptiGen under a=20 long-term storage agreement.
___ Sample (blood or cheek swabs) will be = submitted=20 with this request.
	Sample Storage -- Optional 10 year storage of frozen = sample=20 (BLOOD ONLY) can be requested for an additional $35. No = guarantee=20 is made that this sample will be usable for the desired purpose = when it is=20 retrieved.=20
	Request long-term storage of sample: ___ yes=20 $35 ___ no =

SECTION 6: TEST(S) REQUESTED
Alaskan Malamute	___Cone Degeneration - cd(m) test - $160
American Eskimo Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
American Pit Bull Terrier	___Cone Rod Dystrophy (crd2) - crd2 Test - = $120
	___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia = (NCL-A) -=20 $150
American Staffordshire Terrier	___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia = (NCL-A) -=20 $150
Australian Cattle Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Australian Shepherd	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Australian Shepherd, Miniature	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Australian Shepherd, Toy	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Australian Stumpy Tail Cattle Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Basenji	___Pyruvate Kinase Deficiency - PK test - $80=20 *
Border Collie	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 *
	___Neuronal Ceroid Lipofuscinosis - CL Test - $95=20 *
Boykin Spaniel	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 *
Briard	___Congenital Stationary Night Blindness - CSNB test - = $135=20 *
Bullmastiff	___Canine Multifocal Retinopathy - CMR1 test - $95=20 *
	___Progressive Retinal Atrophy - Dominant test for PRA - = $120=20 *
Cardigan Welsh Corgi	___Progressive Retinal Atrophy - rcd3 test for PRA - $80=20 *
Chesapeake Bay Retriever	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Chinese Crested	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Cockapoo	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Cocker Spaniel (American)	___Phosphofructokinase Deficiency - PFK test - $80=20 *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Collie	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 = -=20 $180 ($144 multiple tests/dog)
Coton de Tulear	___Canine Multifocal Retinopathy - CMR2 test - $95=20 *
Dachshund	___Narcolepsy - NARC test - $130 = *
Doberman Pinscher	___Narcolepsy - NARC test - $130 = *
Dogue de Bordeaux (French Mastiff)	___Canine Multifocal Retinopathy - CMR1 test - $95=20 *
Dwarf Poodle	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
English Cocker Spaniel	___Familial Nephropathy - FN Test - $95=20 *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
English Springer Spaniel	___Phosphofructokinase Deficiency - PFK test - $80=20 *
Entlebucher Mountain Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
FamCollie	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 = -=20 $180 ($144 multiple tests/dog)
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Finnish Lapphund	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
German Shorthaired Pointer	___Cone Degeneration - cd test - $160=20 *
Glen of Imaal Terrier	___Cone Rod Dystrophy (crd3) - crd3 Test - = $120
Golden Retriever	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Goldendoodle	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Great Pyrenees	___Canine Multifocal Retinopathy - CMR1 test - $95=20 *
Greyhound	___Neuropathy - NDRG1 Test - $95
Irish Red & White Setter	___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 = ($105=20 multiple tests/dog) *
	___Progressive Retinal Atrophy - rcd1 test for PRA - $120 = ($95=20 multiple tests/dog) *
Irish Setter	___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 = ($105=20 multiple tests/dog) *
	___Progressive Retinal Atrophy - rcd1 test for PRA - $120 = ($95=20 multiple tests/dog) *
Karelian Bear Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Kuvasz	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Lab/Golden Cross	___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 = multiple tests/dog)
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Labradoodle	___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 = multiple tests/dog)
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Labradoodle, Australian	___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 = multiple tests/dog)
	___Phosphofructokinase Deficiency - PFK test - $80=20 *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Labrador Retriever	___Narcolepsy - NARC test - $130 ($104 multiple tests/dog) = *
	___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 = multiple tests/dog)
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Lancashire Heeler	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 *
Lapponian Herder	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Miniature Poodle	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Miniature Schnauzer	___Progressive Retinal Atrophy - Type A test for PRA - = $160=20 *
Moyen Poodle (Klein Poodle)	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Newfoundland	___Cystinuria - cystinuria test - $80=20 *
Norwegian Elkhound	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Nova Scotia Duck Tolling Retriever	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 ($156 multiple tests/dog) *
Old English Mastiff	___Canine Multifocal Retinopathy - CMR1 test - $95=20 *
	___Progressive Retinal Atrophy - Dominant test for PRA - = $120=20 *
Portuguese Water Dog	___Improper Coat - Improper Coat Test - $80
	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Rough Collie	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 = -=20 $180 ($144 multiple tests/dog)
Samoyed	___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($128 = multiple tests/dog)
	___Progressive Retinal Atrophy - XL test for PRA - $150 = ($120=20 multiple tests/dog) *
Shetland Sheepdog	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 *
Siberian Husky	___Progressive Retinal Atrophy - XL test for PRA - $150=20 *
Silky Terrier	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Sloughi	___Progressive Retinal Atrophy - Sloughi test for PRA - = $80=20 *
Smooth Collie	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 ($144 multiple tests/dog) *
	___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 = -=20 $180 ($144 multiple tests/dog)
Spanish Water Dog	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Swedish Lapphund	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Toy Poodle	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
Whippet, Longhaired	___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - = $180=20 *
Yorkshire Terrier	___Progressive Retinal Atrophy - prcd Mutation Test for = PRA -=20 $195 *
* Tests marked with an asterisk = are not=20 available in all countries. Please visit our website or contact us = for=20 more information.

SECTION 7: CERF or OFA DNA Registry Fee
If you=20 are a US resident, and your dog is one of these - = American=20 Staffordshire Terrier - Briard - Glen of Imaal = Terrier -=20 Irish Setter - Kuvasz - Nova Scotia Duck Tolling=20 Retriever - Old English Mastiff - Shetland = Sheepdog -=20 Spanish Water Dog -- you must include this fee in = your=20 application in accordance with the breed club's guidelines. =
Owners=20 with these breeds from countries other than the USA may choose to = have=20 their dog's DNA registered with CERF or OFA by paying the fee and = checking=20 the box below.
To see which of these registries will receive = your test=20 results directly from OptiGen, please read "Registry Information" = under=20 the "Instructions & Information" tab on the website. =

American Staffordshire Terrier = --	$7.50/test
Briard --	One test requested $15, Each additional test=20 requested on one dog $10
Glen of Imaal Terrier --	$7.50/test
Irish Setter --	One test requested $15, Each additional test=20 requested on one dog $10
Kuvasz --	$7.50/test
Nova Scotia Duck Tolling = Retriever --=20	$7.50/test
Old English Mastiff --	$7.50/test
Shetland Sheepdog --	$7.50/test
Spanish Water Dog --	$7.50/test

=
Number of tests requested __________ Total = CERF or OFA=20 DNA Registry Fee $ __________ =

SECTION 8: Limited Warranty and = Disclaimer
OptiGen=20 warrants its test results to be accurate for the sample obtained = from this=20 dog alone, as identified by the information given on this form. In = the=20 event of a valid claim, owner's sole remedy is a refund of the fee = paid.=20 IN NO EVENT SHALL OPTIGEN BE LIABLE FOR INDIRECT, CONSEQUENTIAL OR = INCIDENTAL DAMAGES OF ANY KIND. Any claim must be asserted within = two=20 years of the report of the test results.

SECTION 9: Certification and = Signatures
The undersigned hereby certifies that the dog described = above is=20 the same dog whose permanent ID (if available) is stated = above,=20 whose sample is submitted and labeled with this name and whose = information=20 is given on this form, and that all information is accurate to the = best of=20 my knowledge. I understand that additional samples may be required = to=20 complete this test. I understand that cheek swab samples are a = less=20 reliable source of DNA and a fee may be charged for repeated = trials on=20 additional cheek swabs in the case of a test failure.

I = authorize=20 OptiGen to release test results to officially sponsored registries = for my=20 breed as described in the Registry=20 Table. I hereby release forever the responsible breed club, = the=20 operators of the registry and OptiGen from any and all liability = resulting=20 from the transfer of this data.

All samples submitted to = OptiGen=20 become the property of OptiGen and may be used for internal = quality=20 control and/or research purposes.

I accept all conditions = stated in=20 this multi-page application form.

Dog's Call = Name:=20	_________________________________________ =
Owner's = Signature:=20	_________________________________	mon/day/yr: =	____/____/____
Sample = Certified by:=20	___Vet/Tech ___ Witness =	Date=20 Collected:	____/____/____
Signature: =	_________________________________	Date =	____/____/____
Print = Name:	_________________________________
Hospital/Clinic (if=20 applicable):	_________________________________________ =
Address:	_________________________________________ =
	_________________________________________=20

SECTION 10: Payment of Fees (no EuroCheques please) =

Total: $ __________ How will you be=20 paying?
___Check or Money Order in US dollars payable to = OptiGen,=20 LLC is enclosed=20

___Visa ___MasterCard =
Credit Card = Number:	________________________________	Expiration Date:	____________
Name on Card:	________________________________	Signature:	_____________________________=20 =

End of=20 Form - Thank you. Last Updated April 22, 2008.