DOGS TEST REQUEST FORM

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  Instructions:
- Fill out the form in all its parts
- After filling out the form complete with all its data, press SEND at the bottom of the page before printing.
- At this point, the form must be:
1. Printed
2. Stamped
3. Signed by the VETERINARY
4. Signed by the OWNER
5. Posted attached to the sample and to the copy of payment.
- The report is mailed to the owner
INFORMATIONS
TEST(S) REQUESTED
DNA sample storage
Parentage determination *
Genetic Identification *

EBJ*   (only EDTA blood sample)
Cystinuria (Newfoundland breed, Bulldog, Labrador) *
VWD1 (Dobermann, Pinscher)
EMOFILIA B (Rhodesian Ridgeback)
Caryo test

*The price is inclusive of DNA sample storage.
PRICE

€ 0,00 Total

   Date of sampling
   City
   Veterinary name
   Note
Information: "Part of the services, under the responsibility of Vetogene Srl, may be entrusted to external testing laboratories that have successfully passed the CT-CG ISAG and / or meeting the requirements
ISO 9001 or ISO 17025 in force. "
"THE TIMES OF TEST RESULTS ARE SUBJECT DELAYS FOR TECHNICAL PROBLEMS RELATED TO THE TYPE AND STORAGE OF BLOOD - RECEIVED DNA "
OWNER INFORMATIONS
Name
Adress
City / Province
Postal code / Country
Phone
E-mail
 
INVOICE DATA  (if are different from owner )
Name
Adress
 



Certification     (required)
The undersigned authorizes  "Vetogene" at the processing of personal data transmitted pursuant to Decree Legislative  No. 196, 2003 (D.Leg.196/2003) and give my consent to data processing and possibly biological material for research purposes (whose results will be released so as not to identify the source)
DOG IDENTIFICATION
Registered Name
Breed
Sex
Birthdate
Mantle
Registration number
Tattoo
Chip


* required tattoo or chip
FAMILY DOG INFORMATIONS
Registered name of Sire
Registered number of Sire
Registered name of Dam
Registered number of Dam