INTERNAL USE ONLY Orivet Genetic Pet Care R&D PO Box 110 St Kilda 3182 VIC PHONE: 03 9560 2000 FAX: 03 9560 2200 EMAIL: [email protected] A.B.N. 87 225 165 899 Recollection (Lab ID) Molecular (DNA) Testing Application Form www.orivet.com.au Please print clearly. If submitting more than one sample, complete all sections for the first animal. Complete ONLY & for all additional animals Owner’s Name: 1 Address: Suburb: State: Postcode: Country: Mobile No: Contact No: Email: *Required for login access TEST REQUIRED & ANIMAL’S DETAILS Canine (Dog): Barcode Feline (Cat): FOR A LIST OF ALL DISEASES AND CODES REFER TO BACK OF THIS SHEET Full Canine Breed Profile Other: Write or Place Barcode Number Here Barcode can be found inside the Swab Packaging Includes all diseases, traits and a DNA Profile for your breed Full Feline Genetic Screen Includes all diseases & traits Code Test 1: Full Feline Disease Profile or Code Test 2: Includes all diseases Code Test 3: Full Feline Trait Profile Includes all traits 2 Parentage: DNA Profiling Please Tick One For Parentage Evaluation Only Dam Progeny Sire Normal By Parentage Registered Name: Pet Name: Sex: Male Female Breed: Registration No: Microchip No: PAYMENT DETAILS For all charges please see the Orivet DNA fee schedule or refer to website No samples will be processed without payment details Pay ONLINE and receive a 10% Discount (Please submit confirmation of payment with form) Method of Payment: Make cheques payable to: “Orivet Genetic Pet Care” Cardholders Name: Credit Card No: 3 Expiry Date: $ CCV No: Last 3 digits located on the back of your card If paying By EFTPOS Account Name: ORIVET Genetic Pet Care. BSB 033-047. Account 608145. (International Clients) SWIFT CODE: WPACAU2S OWNER’S CONSENT Signature COLLECTOR’S DETAILS I hereby acknowledge that the sample(s) identified on this application form are from the animal(s) identified above. 4 Please Tick: Samples are the property of the owner and cannot be used for any future research or passed onto any third parties without owners consent. Owners who are members of a particular breed club or part of an approved breeding scheme consent for the information to be passed onto those approved schemes. Signature By signing above you accept the terms and conditions as outlined on the web site. By signing below I consent to be notified of any carrier or affected results, whether the test was requested or not. Signature Collected by Owner (Details below not required) Collected by a Collection Agent 5 Agent ID: Collected by a Vet VGA Exam Included Date of Collection: / / Collector’s Name : Name of Clinic: Please Note: No Collection Agents receive results. Orivet Molecular (DNA) Testing Form (2014) / Signature CANINE GENERAL CODE DNA Profile Full Breed Profile Storage Breed Identification Recollection (Failed Sample) No Charge C-DNAP C-FBPR C-STOR C-BRID C-RECO CANINE DISEASES Alport Syndrome (Hereditary Nephritis) Arrythmogenic Right Ventricular Cardiomyopathy Autosomal Hereditary Recessive Nephropathy Black Hair Follicular Dysplasia Canine Hyperuricosuria Canine Leukocyte Adhesion Deficiency Canine Multifocal Retinopathy Catalase Deficiency Centronuclear Myopathy *Cerebella Ataxia Chondrodysplasia Cobalamin Malabsorption *Collie Eye Anamoly/Choroidal Hyperplasia 1 Cone Degeneration (CNGB3) Congenital Hypothyroidism Congenital Stationary Night Blindness Copper Toxicosis Curly Coat Dry Eye Cystinuria Degenerative Myelopathy Dilated Cardiomyopathy Dominant - PRA Dwarfism (Pituitary) Ectodermal Dysplasia (FOX 13) Episodic Falling Exercise Induced Collapse Factor VII Deficiency Fucosidosis Globoid Cell Leukodystrophy/ Krabbe’s Disease GM1 – Gangliosidosis Generalised PRA Gray Collie Syndrome (canine cyclic neutropenia) Hereditary Cataract Hereditary Nephritis Ivermectin Sensitivity MDR1 Juvenile Epilepsy L-2-hydroxyglutaric Aciduria Merle Mucopolysaccharidosis Muscular Dystrophy X-linked (MDX) Musladin-Leuke Syndrome Myotonia Congenita Myotubular Myopathy X linked Narcolepsy Neonatal Ataxia Neonatal Cerebellar Cortical Degeneration Neonatal Encephalopathy Neuronal Ceroid Lipofuscinosis Open Angle Glaucoma Phosphofructokinase Deficiency Polyneuropathy/Neuropathy (NDRG1) Pompes Disease Prekallikrein Deficiency Primary Ciliary Dyskinesia Primary Lens Luxation Progressive Retinal Atrophy cord1 Progressive Retinal Atrophy - rcd 3 C- ALPS C-ARVC C-AHRN C-BHFD C-CHYP C-CLAD C-CMRY C-CTDY C-CNMY C-CRAX C-CHON C-CBMN C- CEAH C-CDGN C-COHY C-CSNB C-COTX C-CCDE C-CYST C-DGMY C-DCMY C-DPRA C-DWFS C-ECTD C-EPFL C-EICS C-FVII C-FUCO C-GCLY C-GNGS C-GPRA C-GCSM C-HCTT C-HRNP C-IVMY C-JVEY C-LHGA C-MERL C-MUCO C-MDXL C-MSLS C-MYCO C-MYMX C-NARC C-NEAT C-NCBC C-NENY C-NCLA C-OAGC C-PHDF C-PLNY C-PMDS C-PKDC C-PCDA C-PLLX C-CORD C- PRA3 Progressive Retinal Atrophy -Rcd1 Progressive Retinal Atrophy -rcd1a Progressive Retinal Atrophy -rcd4 *Progressive Rod Cone Degeneration - PRA Pyruvate Dehydrogenase Phosphatase 1 Deficiency Pyruvate Kinase Deficiency Renal Cystadenocarcinoma **Renal Dysplasia Skeletal Dysplasia Startle Disease Thrombopathia Trapped Neutrophil Syndrome Type A - PRA von Willebrand’s Disease Type I von Willebrand’s Disease Type II von Willebrand’s Disease Type III X Linked PRA C-PRA1 C-PRAA C-PRA4 C-PRCD C-PDP1 C-PKDY C-RCCA C-RNDY C-SKDY C-STDS C-THRM C-TNSN C-PRAA C-VWD1 C-VWD2 C-VWD3 C-XLPA CANINE TRAITS Long Hair Gene Natural Bob Tail A-Locus Agouti B (Brown) Locus D (Dilute) Locus K Locus EM-Locus Melanistic Mask Allele (Em), E-Locus E-Locus (yellow, lemon, red, cream and appricot) Spotting gene (W Locus) C-LHGN C-NBTL C-CCAG C-CCBL C-CCDL C-CCKL C-CEML C-CCEL C-CCSW FELINE GENERAL DNA Profile Full Disease Profile Full Trait Profile Full Genetic Screen - Diseases and Traits Storage Recollection (Failed Sample) No Charge F-DNAP F-DISP F-TRIP F-GDTP F-STOR F-RECO FELINE DISEASES Familial Episodic Hypokalamic Polymyopathy Gangliosidosis GM2 Glycogen Storage Disease Hypertrophic Cardiomyopathy Mucopolysaccharodosis Niemann Pic Disease Polycystic Kidney Disease Progressive Retinal Atrophy Pyruvate Kinase Deficiency Spinal Muscular Atrophy F-FEHP F-GNGG F-GSDS F-HCMY F-MUCO F-NPDS F-PKDD F-PRAY F-PYKD F-SMAT FELINE TRAITS Agouti Albinism Amber Blood Groups Chocolate and Cinnamon Test Colourpoint Restriction Test (Points) Dilute Gloves (White) Longhair/Shorthair F-AGOU F-ALBN F-AMBR F-BGRP F-CHCN F-CPRT F-DLTE F-GLVS F-LHSH * These tests have patent and restrictions apply. Contact Orivet for further information. ** This test is a send out and a separate set of swabs MUST be submitted. Orivet Molecular (DNA) Testing Form (2014) Molecular (DNA) Testing Application Codes
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