Sample #:____________ Date:_________________

FOR OFFICE USE ONLY

3382 Capital Cr. NE Tallahassee FL 32308
Account # _________________ Date: _____________
Canine Sample Submission Form
SUBMITTED BY

Name:___________________________________________ Business Name:____________________________________________________________

Address: ____________________________________________________________City: ___________________________________ State: _______

ZipCode:___________Country:_______________Phone#:__________________________E-mail: ____________________________________________
OWNER

Name:__________________________________________ Business Name:_____________________________________________________________

If Different

Address:__________________________________________________City:________________________State:_______ ZipCode:___________

Dog Information:
Name: ____________________________________________ Registration #:__________________________Microchip #:___________________________
DOG INFORMATION

Breed: ________________________________ Gender: ___________ Coat Color _______________________ Date of Birth: ________________________

Parents of Dog *not required*

Sire’s Name: _________________________________________________________________________________________________________________

Registration: _________________________________ Breed: ________________________________________ Color: ____________________________

Dam’s Name: _________________________________________________________________________________________________________________

Registration: ________________________________ Breed: __________________________________________ Color: _____________________________

Test For Coat Color Test For Genetic Disorders

 A Locus - Ay (Sable/Fawn)  ARVC  DMS  IVDD  POAG

 A Locus - Aw (Wild Sable)  AMS  EFS CKCS-EF  JHC  POAG-PLL
 A Locus - At (Tricolor/Tan Points)  CEA  EIC  MD  PRA-CNGA1
 A Locus - a (Solid Black)  CD (Cone Degeneration)  Factor VII  MDR1  PRA-Cord1
 Complete A Locus Profile
 CKCSID  Fucosidosis  MH  PRA-Dominant
 B Locus - b (Chocolate/Red)
 C Locus - Cocoa (French Bulldog)  CLAD  FN  MLS  PRA-rcd1
 D Locus - d1-2 (Dilute Blue/Lilac)  CMO  Glaucoma (BC)  NA  PRA-rcd3
 E Locus - e (Black/Yellow)  CMR1  GR-PRA1  NCCD  PRA-prcd
TESTING INFORMATION

 E Locus - EM (Mask)  CMR2  GR-PRA2  NCL  TNS

 H Locus - Harlequin  CN/Gray Collie  HC  NEwS  VWDI
 K Locus - KB (Dominant Black)
 CNM  HGA  OI  VWDII
 M Locus - Merle
 S Locus - S (Piedbald, Parti)  Cystinuria (Newfies and Labs only)  HNPK  PFK  VWDIII
 Complete Color Profile *No Merle  DCM 1-2  HUU  PH  Z-Factor (OA)
(Doberman Pinschers only)
 DH/Raine’s Syndrome  ICT/ICH  PKD
 DM  IGS  PLL
Test For Coat Type
 Hair Curl (1&2)
 Hair Furnishings (1&2)
 Hair Length (1-5) Combination Panels
Boxer Australian Shepherd Staffordshire Bull Terrier Labradoodle
 Hair Shedding Collie Golden Retriever Pembroke Welsh Corgi Goldendoodle
 Bobtail Gene
Beagle Labrador Retriever Coton de Tulear Shetland Sheepdog
 Complete Coat Type Panel
Includes Curl, Furnishings, Length & Shedding Poodle American Bulldog English Springer Spaniel _______________
Doberman English Bulldog Cocker Spaniel
DNA Profile/Parentage
Border Collie French Bulldog Cavalier King Charles Spaniel
 ISAG DNA profile

Payment Amount: ________  Check #_________ Money Order Credit Card PayPal paypal@animalgenetics.com
INFORMATION
PAYMENT

Test results and invoice are sent via email as PDF. Check here for a copy of results by US Mail  Credit Card Information
Print name on card: Card #: Exp. Date:

Signature of cardholder: Billing zip code (postal code): 3 or 4 digit security code #:

By submitting this form, the customer understands that Animal Genetics Inc. retains full ownership of sample and shall in no way be liable for any incidental or
consequential damages of any kind. Animal Genetics Inc. is not responsible for the origin/source of samples submitted by the individual customer. For future release,
Animal Genetics may run additional tests on the sample submitted that are not requested on this form.