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spacer OptiGen - Link to Translated Form Request Test
Instructions
This form is for submitting a test application to OptiGen ONLINE. Because the computer program will time out after a while, you should assemble all the information you will need in advance. If you are not sure what you need, go back (with your browser back button) and print a copy of the "Printable Form" to see the questions you will be asked.

You will be asked to print the following page, obtain signatures on it, and then include it with the sample package you send to OptiGen. Please read and print a copy of the Ship Sample instructions. If you do not want to submit your application online, please use our printable blank form which can be duplicated and completed by hand.

Sample Information
Sample is already at OptiGen either under a long-term storage agreement or because the dog was previously tested.
Sample (blood, semen, or cheek swabs) will be submitted with this request.
  Sample Storage: Optional 10 year storage of frozen sample (BLOOD ONLY) can be requested for an additional $35. No guarantee is made that this sample will be usable for the desired purpose when it is retrieved.
Request long-term storage of sample yes no

Owner Information
Where labels are in bold type, the information is required.
first initial  last
Name:
Address:
Continued Address:
City:
State/Province:
Zip/Postal Code:
Country:

Day Phone:

Evening Phone:
Fax:
Email:
first initial  last
Co-Owner Names:

Reports
ALL reports are mailed to the owner. Results will not be provided by phone.
For additional rapid reports, select one

Test results will be reported to genetic registries only according to policy determined by each parent club as described in the Registry Table. To request additional, mailed reports to anyone other than the owner or qualified, please include an addressed envelope for each name and address (no postage).

Dog Identification
Breed:
If the dog's breed is NOT in the breed list, enter the breed here:
Call Name:
Registry: N/A
If the dog's registry is NOT in the above list, enter the registry's name here:
Registered Name: N/A
Registration #: N/A
Birthdate:
Month Day Year
Sex: Female Male
Tattoo/Chip#: N/A
CERF#/Other Eye Registry#: N/A
Registered Name of Sire: N/A
Registered Number of Sire: N/A
Registered Name of Dam: N/A
Registered Number of Dam: N/A

Disease History
Date of last exam by an ophthalmologist:
Never Examined
Month Day Year
Eye Disease Diagnosed:
Comment:
Other Disease Diagnosed:
Comment:

If available, please provide information on the examining ophthalmologist or veterinary specialist.
first initial  last
Name:
Address:
Continued Address:
City:
State/Province:
Zip/Postal Code:
Country:

Phone:

Fax:
Email:

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


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OptiGen®, LLC · Cornell Business & Technology Park · 767 Warren Road, Suite 300 · Ithaca, New York 14850
Tel: 607 257 0301 · Fax: 607 257 0353 · email: genetest@optigen.com or optigen@clarityconnect.com
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