OPTIGEN Test Request Form
INSTRUCTIONS
This form is for submitting a test application to OptiGen by mail or fax. Feel free to duplicate and distribute this form to others. Please complete the form carefully and be sure to obtain the required signatures on it, then include one copy with payment in the sample package you send to OptiGen. Please read and print a copy of the Ship Sample instructions. Ship sample(s) to OptiGen, 767 Warren Road, Suite 300, Ithaca, NY 14850. If you want to submit your application online, please use our online form.
SECTION 1: OWNER INFORMATION
Name: first________________________  initial ______  last_________________________________
Address: __________________________________________________________________________
City: _____________________________ State/Province: ___________________________
Country: _____________________________ Zip/Postal Code: ___________________________
Day Phone: _____________________________ Evening Phone: ___________________________
Fax: _____________________________
Email: __________________________________________________________________________
Co-Owner Names:
first ________________________  initial ______   last _________________________________ 
________________________  ______   _________________________________ 
________________________   ______  _________________________________ 
SECTION 2: REPORTS
  X   Mail   ALL reports are mailed to the owner. For additional rapid reports, select one:        Email  or         Fax  
Results will not be provided by phone. 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 registry, please include an addressed envelope for each name and address (no postage).


SECTION 3: Dog Identification    (Indicate "N/A" if question not applicable)
Breed: _______________________________ Call Name: _____________________________
Registry: __________________________________________________________________________
Registered Name: __________________________________________________________________________
Registration #: __________________________________________________________________________
Birthdate: ____/____/____ (mon/day/yr)     Sex: ___Female  ___Male
Tattoo/Chip#: _________________________________   CERF#/Other Eye Registry#: _________________
Registered Name of Sire: __________________________________________________________________________
Registered Number of Sire: __________________________________________________________________________
Registered Name of Dam: __________________________________________________________________________
Registered Number of Dam: __________________________________________________________________________

SECTION 4: Disease History
Date of last exam by an ophthalmologist (mon/day/yr): ____/____/_____   or  ___ never examined
Eye Disease History: 
    ____ None    ____ Other
___ Canine Multifocal Retinopathy
___ Cataracts
___ Collie Eye Anomaly/Choroidal Hypoplasia
___ Coloboma
___ Cone Degeneration
___ Cone Degeneration (cdm)
___ Cone Rod Dystrophy (crd2)
___ Cone Rod Dystrophy (crd3)
___ Cone Rod Dystrophy 1/Rod Cone Dysplasia 1b
___ Cone-Rod Dystrophy
___ Congenital Stationary Night Blindness
___ Day Blindness
___ Day Blindness/Retinal Degeneration
___ Distichiasis
___ Early Retinal Degeneration
___ Glaucoma
___ Hereditary Cataracts - HSF4-1
___ Hereditary Cataracts - HSF4-2
___ Iris Melanoma
___ Pigmentary Uveitis
___ Primary Lens Luxation
___ Progressive Retinal Atrophy
___ Retinal Dysplasia Geographic
___ Retinal Dysplasia/Retinopathy
___ Retinal Folds
___ Suspicious-PRA
Comment:
___________________________________
___________________________________
Other Disease:
    ___ None    ___ Other
___ ACRAL Mutilation Syndrome
___ Benign Familial Juvenile Epilepsy
___ Canine Leukocyte Adhesion Deficiency
___ Central Nuclear Myopathy
___ Craniomandibular Osteopathy
___ Curly Hair
___ Cystinuria
___ Degenerative Myelopathy
___ Dermatomyositis
___ Epilepsy
___ Epilepsy
___ Exercise Induced Collapse
___ Exocrine Pancreatic Insufficiency
___ Familial Nephropathy
___ Gangliosidosis
___ Hereditary Nasal Parakeratosis
___ Histiocytic Sarcoma
___ Hydroxyglutaric Aciduria
___ Hyperuricosuria
___ Ichthyosis
___ Imerslund Grasbeck syndrome
___ Improper Coat
___ L-2-Hydroxyglutaric Aciduria
___ Lysosomal Storage Disease
___ Myotonia Congenita
___ Narcolepsy
___ Neonatal Encephalopathy with Seizures
___ Neuroaxonal Dystrophy
___ Neurological Disease
___ Neuronal Ceroid Lipofuscinosis
___ Neuropathy
___ Oculocutaneous Albinism
___ OculoSkeletal Dysplasia
___ Osteochondrodysplasia
___ Persistent Muellerian Duct Syndrome
___ Phosphofructokinase Deficiency
___ Primary Ciliary Dyskinesia
___ Pyruvate Kinase Deficiency
___ Rage
___ Skeletal Dysplasia2
___ Trapped Neutrophil Syndrome
If available, please provide information on the examining ophthalmologist or veterinary specialist.
Name: _____________________________________________________________________
Address: _____________________________________________________________________
City: _____________________________ State/Province: _____________________________
Zip/Postal Code: _____________________________ Country: _____________________________
Phone: _____________________________ Fax: _____________________________
Email: _____________________________________________________________________

SECTION 5: SAMPLE INFORMATION
___ Blood sample is already at OptiGen under a long-term storage agreement.
___ Sample (blood 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 $35    ___ no

SECTION 6: TEST(S) REQUESTED
American Pit Bull Terrier  ___Cone Rod Dystrophy (crd2) - crd2 Test - $100 ($90 multiple tests/dog)
   ___Cone Rod Dystrophy 1/Rod Cone Dysplasia 1b - crd1/rcd1b test - $75 ($65 multiple tests/dog)
   ___Hyperuricosuria - HUU Test - $75 ($65 multiple tests/dog)
   ___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia (NCL-A) - $100 *
American Staffordshire Terrier  ___Cone Rod Dystrophy 1/Rod Cone Dysplasia 1b - crd1/rcd1b test - $75 ($65 multiple tests/dog)
   ___Hyperuricosuria - HUU Test - $75 ($65 multiple tests/dog)
   ___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia (NCL-A) - $100 *
Australian Cattle Dog  ___Primary Lens Luxation - PLL Test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Australian Cobberdog  ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Basenji  ___Progressive Retinal Atrophy - Bas_PRA1 test - $75 ($65 multiple tests/dog)
   ___Pyruvate Kinase Deficiency - PK test - $75 ($65 multiple tests/dog) *
Bernedoodle  ___Day Blindness - DB/RD test - $130 ($120 multiple tests/dog)
   ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Neonatal Encephalopathy with Seizures - NEwS Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Bernese Mountain Dog  ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Histiocytic Sarcoma - HS test - $130
Border Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $130 ($120 multiple tests/dog) *
   ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Imerslund Grasbeck syndrome - I-GS test - $75 ($65 multiple tests/dog)
   ___Neuronal Ceroid Lipofuscinosis - CL Test - $75 ($65 multiple tests/dog)
   ___Trapped Neutrophil Syndrome - TNS Test - $75 ($65 multiple tests/dog)
Boston Terrier  ___Cataracts - HSF4-1 test for Cataracts - $100 ($90 multiple tests/dog) *
Briard  ___Congenital Stationary Night Blindness - CSNB test - $130 ($120 multiple tests/dog) *
Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $130 ($120 multiple tests/dog) *
   ___Dermatomyositis - DMS - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $130 ($120 multiple tests/dog)
Danish Pointing Dog  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75
Doberman Pinscher  ___Narcolepsy - NARC test - $100 ($90 multiple tests/dog) *
   ___Oculocutaneous Albinism - WDP_OCA Test - $75 ($65 multiple tests/dog)
Dwarf Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
English Cocker Spaniel  ___ACRAL Mutilation Syndrome - AMS Test - $100
   ___Exercise Induced Collapse - EIC test - $75 ($65 multiple tests/dog) *
   ___Familial Nephropathy - FN Test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
English Setter  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
French Bulldog  ___Cataracts - HSF4-1 test for Cataracts - $100 ($90 multiple tests/dog) *
Glen of Imaal Terrier  ___Cone Rod Dystrophy (crd3) - crd3 Test - $100 ($90 multiple tests/dog)
Golden Retriever  ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Ichthyosis - Ichthyosis - $100 *
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA2 - $100 ($90 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Goldendoodle  ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Day Blindness/Retinal Degeneration - DB/RD test - $130 ($120 multiple tests/dog)
   ___Ichthyosis - Ichthyosis - $100 *
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA2 - $100 ($90 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Gordon Setter  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Greyhound  ___Neuropathy - NDRG1 Test - $75 ($65 multiple tests/dog)
Irish Red & White Setter  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Canine Leukocyte Adhesion Deficiency - CLAD test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd1 test for PRA - $100 ($90 multiple tests/dog) *
Irish Setter  ___Canine Leukocyte Adhesion Deficiency - CLAD test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd1 test for PRA - $100 ($90 multiple tests/dog) *
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Italian Greyhound  ___Progressive Retinal Atrophy - IG-PRA1 test - $100 ($90 multiple tests/dog)
Japanese Spitz  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Lab/Golden Cross  ___Central Nuclear Myopathy - CNM test - $75 ($65 multiple tests/dog)
   ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Ichthyosis - Ichthyosis - $100 *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA2 - $100 ($90 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Labradoodle  ___Central Nuclear Myopathy - CNM test - $75 ($65 multiple tests/dog)
   ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Day Blindness/Retinal Degeneration - DB/RD test - $130 ($120 multiple tests/dog)
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Labradoodle Goldendoodle Cross  ___Central Nuclear Myopathy - CNM test - $75 ($65 multiple tests/dog)
   ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Day Blindness/Retinal Degeneration - DB/RD test - $130 ($120 multiple tests/dog)
   ___Ichthyosis - Ichthyosis - $100 *
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___Narcolepsy - NARC test - $100 ($90 multiple tests/dog) *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA2 - $100 ($90 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Labradoodle, Australian  ___Central Nuclear Myopathy - CNM test - $75 ($65 multiple tests/dog)
   ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Day Blindness/Retinal Degeneration - DB/RD test - $130 ($120 multiple tests/dog)
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Labrador Retriever  ___Central Nuclear Myopathy - CNM test - $75 ($65 multiple tests/dog)
   ___Day Blindness - ACHM2-LR Test - $100 ($90 multiple tests/dog)
   ___Exercise Induced Collapse - EIC test - $75 ($65 multiple tests/dog) *
   ___Hyperuricosuria - HUU Test - $75 ($65 multiple tests/dog)
   ___Narcolepsy - NARC test - $100 ($90 multiple tests/dog) *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
   ___Skeletal Dysplasia2 - SD2 Test - $75 ($65 multiple tests/dog)
Lapponian Herder  ___Canine Multifocal Retinopathy - CMR3 test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Large Munsterlander  ___Hyperuricosuria - HUU Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Llewellyn Setter  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Miniature Poodle  ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Osteochondrodysplasia - Osteochondrodysplasia Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Miniature Schnauzer  ___Persistent Muellerian Duct Syndrome - PMDS test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - Type B PRA - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - Type A test for PRA - $130 ($120 multiple tests/dog) *
Moyen Poodle (Klein Poodle)  ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Osteochondrodysplasia - Osteochondrodysplasia Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Papillon  ___Neuroaxonal Dystrophy - NAD test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - Pap_PRA1 - $75 ($65 multiple tests/dog)
Phalene  ___Neuroaxonal Dystrophy - NAD test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - Pap_PRA1 - $75 ($65 multiple tests/dog)
Polish Lowland Sheepdog  ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Portuguese Water Dog  ___Curly Hair - Curly Hair Test - $75 ($65 multiple tests/dog)
   ___Gangliosidosis - GM1 - $100 ($90 multiple tests/dog)
   ___Improper Coat - Improper Coat Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - EOPRA test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Rough Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $130 ($120 multiple tests/dog) *
   ___Dermatomyositis - DMS - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $130 ($120 multiple tests/dog)
Samoyed  ___OculoSkeletal Dysplasia - Inherited RD/OSD - $130 ($120 multiple tests/dog)
   ___Progressive Retinal Atrophy - XL test for PRA - $130 ($120 multiple tests/dog) *
Shetland Sheepdog  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $130 ($120 multiple tests/dog) *
   ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Dermatomyositis - DMS - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - CNGA1-PRA Test - $75 ($65 multiple tests/dog)
Siberian Husky  ___Progressive Retinal Atrophy - XL test for PRA - $130 ($120 multiple tests/dog) *
Small Munsterlander  ___Hyperuricosuria - HUU Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
Smooth Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $130 ($120 multiple tests/dog) *
   ___Dermatomyositis - DMS - $100 ($90 multiple tests/dog)
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $130 ($120 multiple tests/dog)
Staffordshire Bull Terrier  ___Cataracts - HSF4-1 test for Cataracts - $100 ($90 multiple tests/dog) *
   ___L-2-Hydroxyglutaric Aciduria - L-2-HGA test - $75 ($65 multiple tests/dog)
Standard Poodle  ___Day Blindness/Retinal Degeneration - DB/RD test - $130 ($120 multiple tests/dog)
   ___Degenerative Myelopathy - DM Test - $75 ($65 multiple tests/dog) *
   ___Neonatal Encephalopathy with Seizures - NEwS Test - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *
Tibetan Terrier  ___Primary Lens Luxation - PLL Test - $75 ($65 multiple tests/dog) *
   ___Progressive Retinal Atrophy - PRA3 - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - rcd4 test for PRA - $75 ($65 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $130 ($120 multiple tests/dog) *

* Tests marked with an asterisk are not available in all countries. Please visit our website or contact us for more information.

SECTION 7: CERF or OFA DNA Registry Fee
If you are a US resident, and your dog is one of these - American Staffordshire Terrier - Briard - German Shorthaired Pointer - Glen of Imaal Terrier - Irish Setter - Kuvasz - Mastiff (English) - Nova Scotia Duck Tolling Retriever - Shetland Sheepdog - Spanish Water Dog -- you must include this fee in your application in accordance with the breed club's guidelines.
Owners with these breeds from countries other than the USA may choose to have their dog's DNA registered with CERF or OFA by paying the fee and checking the box below.
To see which of these registries will receive your test results directly from OptiGen, please read "Registry Information" under the "Instructions & Information" tab on the website.


American Staffordshire Terrier -- $7.50/test
Briard -- $7.50/test
German Shorthaired Pointer -- $7.50/test
Glen of Imaal Terrier -- $7.50/test
Irish Setter -- $7.50/test
Kuvasz -- $7.50/test
Mastiff (English) -- $7.50/test
Nova Scotia Duck Tolling Retriever -- $7.50/test
Shetland Sheepdog -- $7.50/test
Spanish Water Dog -- $7.50/test

Number of tests requested __________   Total CERF or OFA DNA Registry Fee $ __________

SECTION 8: 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.

SECTION 9: Certification and Signatures
The undersigned hereby certifies that the dog described above is the same dog whose <B>permanent ID</B> (if available) is stated above, whose sample is submitted and labeled with this name and whose information is given on this form, and that all information is accurate to the best of my knowledge. I understand that additional samples may be required to complete this test. I understand that cheek swab samples are a less reliable source of DNA and a fee may be charged for repeated trials on additional cheek swabs in the case of a test failure.

I authorize OptiGen to release test results to officially sponsored registries for my breed as described in the <A HREF="opt9_ogregistryonline.html">Registry Table</A>. I hereby release forever the responsible breed club, the operators of the registry and OptiGen from any and all liability resulting from the transfer of this data.

All samples submitted to OptiGen become the property of OptiGen and may be used for internal quality control and/or research purposes.

I accept all conditions stated in this multi-page application form.


Dog's Call Name: _________________________________________
Owner's Signature: _________________________________ mon/day/yr: ____/____/____
Sample Certified by: ___Vet/Tech  ___ Witness Date Collected:  ____/____/____
Signature: _________________________________ Date ____/____/____
Print Name: _________________________________
Hospital/Clinic (if applicable): _________________________________________
Address: _________________________________________
  _________________________________________
SECTION 10: Payment of Fees (no EuroCheques please)
Total: $ __________   How will you be paying?
 ___Check or Money Order in US dollars payable to OptiGen, LLC is enclosed
___Visa ___MasterCard
Credit Card Number: ________________________________ Expiration Date: ____________
Name on Card: ________________________________ Signature: _____________________________


End of Form - Thank you. Last Updated April 22, 2008.