Owner Name ________________________________________________________

Breeder Street _______________________________________________________

Veterinarian City __________________________ State ______ Zip ____________

Phone _____________________________ Fax _____________________________

Email __________________________________________________________

Date of sample collection ___________________________

Animal’s Name ____________________________ Date of Birth _______________

Species: (___) Dog      (___) Cat      AKC# ________________________

Sex: (___) Female      (___) Male      CFA# ________________________

Neutered: (___) Yes      (___) No      Other# _______________________

Sire/Tom _________________________________ AKC/CFA# ___________________

Dam/Queen _______________________________ AKC/CFA# ___________________

Reason for Testing (select all that apply)

(___) General Genetic Screening      (___) Showing

(___) Suspicious Clinical Signs      (___) Breeding

(___) Puppy or Kitten (at least four weeks old)

(___) Relative known to be affected (please state who) _____________________________

(___) Other (explain) ________________________________________________________

Tests to be conducted

(___) PK DNA screening only $75

(___) Blood Typing only $15

(___) Both PK DNA screening and Blood Typing $90

Please send the sample, form, and check payable to "Trustees, Univ. of PA/Giger" 2-day 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