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
___ Congenital Stationary Night Blindness
___ Primary Lens Luxation
___ Progressive Retinal Atrophy
___ Retinal Folds
 Comment:
___________________________________
___________________________________
Other Disease:
    ___ None    ___ Other
 ___ Canine Leukocyte Adhesion Deficiency
___ Cystinuria
___ Epilepsy
___ Familial Nephropathy
___ Myotonia Congenita
 ___ Narcolepsy
___ Neuronal Ceroid Lipofuscinosis
___ Phosphofructokinase Deficiency
___ Pyruvate Kinase Deficiency
___ Rage
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 Cocker Spaniel  ___Phosphofructokinase Deficiency - PFK test - $80 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
American Eskimo Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Australian Cattle Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Australian Shepherd  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
 ___COMBO - CEA/CH test/prcd Mutation Test for PRA - $300
Australian Shepherd, Miniature  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
 ___COMBO - CEA/CH test/prcd Mutation Test for PRA - $300
Australian Stumpy Tail Cattle Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Basenji  ___Pyruvate Kinase Deficiency - PK test - $80
Border Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
 ___Neuronal Ceroid Lipofuscinosis - CL Test - $95
Boykin Spaniel  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Briard  ___Congenital Stationary Night Blindness - CSNB test - $135 *
Bullmastiff  ___Canine Multifocal Retinopathy - CMR1 test - $95 *
 ___Progressive Retinal Atrophy - Dominant test for PRA - $120
Cardigan Welsh Corgi  ___Progressive Retinal Atrophy - rcd3 test for PRA - $80 *
Chesapeake Bay Retriever  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Chinese Crested  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Cockapoo  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Coton de Tulear  ___Canine Multifocal Retinopathy - CMR2 test - $95 *
Dachshund  ___Narcolepsy - NARC test - $130 *
Doberman Pinscher  ___Narcolepsy - NARC test - $130 *
Dogue de Bordeaux (French Mastiff)  ___Canine Multifocal Retinopathy - CMR1 test - $95 *
Dwarf Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
English Cocker Spaniel  ___Familial Nephropathy - FN Test - $95 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
English Springer Spaniel  ___Phosphofructokinase Deficiency - PFK test - $80 *
Entlebucher Mountain Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Finnish Lapphund  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
German Shorthaired Pointer  ___Cone Degeneration - cd test - $160 *
Golden Retriever  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Goldendoodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Great Pyrenees  ___Canine Multifocal Retinopathy - CMR1 test - $95 *
Irish Red & White Setter  ___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 *
 ___Progressive Retinal Atrophy - rcd1 test for PRA - $120
 ___COMBO - CLAD test/rcd1 test for PRA - $200
Irish Setter  ___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 *
 ___Progressive Retinal Atrophy - rcd1 test for PRA - $120
 ___COMBO - CLAD test/rcd1 test for PRA - $200
Karelian Bear Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Kuvasz  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Lab/Golden Cross  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Labradoodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Labradoodle, Australian  ___Phosphofructokinase Deficiency - PFK test - $80 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
Labrador Retriever  ___Narcolepsy - NARC test - $130 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
 ___COMBO - NARC test/prcd Mutation Test for PRA - $260
Lancashire Heeler  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Lapponian Herder  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Miniature Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Miniature Schnauzer  ___Progressive Retinal Atrophy - Type A test for PRA - $160 *
Newfoundland  ___Cystinuria - cystinuria test - $80 *
Nova Scotia Duck Tolling Retriever  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
 ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195
 ___COMBO - CEA/CH test/prcd Mutation Test for PRA - $300
Old English Mastiff  ___Canine Multifocal Retinopathy - CMR1 test - $95 *
 ___Progressive Retinal Atrophy - Dominant test for PRA - $120
Portuguese Water Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Rough Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Samoyed  ___Progressive Retinal Atrophy - XL test for PRA - $150 *
Shetland Sheepdog  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Siberian Husky  ___Progressive Retinal Atrophy - XL test for PRA - $150 *
Sloughi  ___Progressive Retinal Atrophy - Sloughi test for PRA - $80 *
Smooth Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Spanish Water Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Swedish Lapphund  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Toy Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Whippet, Longhaired  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *

* 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 - Australian Cattle Dog - Briard - Irish Setter - Kuvasz - Nova Scotia Duck Tolling Retriever - Old English Mastiff - Spanish Water Dog -- you must include this fee in your application in accordance with the breed club's guidelines.
Owners from other countries with these breeds may choose to have their dog's DNA registered with CERF or OFA by paying the fee and checking the box below.


Australian Cattle Dog -- $7.50/test
Briard -- One test requested $15, Each additional test requested on one dog $10
Irish Setter -- One test requested $15, Each additional test requested on one dog $10
Kuvasz -- One test requested $7.50, Each additional test requested on one dog $
Nova Scotia Duck Tolling Retriever -- $7.50/test
Old English Mastiff -- $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 permanent ID (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 Registry Table. 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.

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.