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
___ Congenital Stationary Night Blindness
___ Distichiasis
___ Glaucoma
___ 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
 ___ Benign Familial Juvenile Epilepsy
___ Canine Leukocyte Adhesion Deficiency
___ Cystinuria
___ Epilepsy
___ Epilepsy
___ Familial Nephropathy
___ Ichthyosis
___ Improper Coat
___ Myotonia Congenita
 ___ Narcolepsy
___ Neuronal Ceroid Lipofuscinosis
___ Neuropathy
___ OculoSkeletal Dysplasia
___ Phosphofructokinase Deficiency
___ Pyruvate Kinase Deficiency
___ Rage
___ 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
Alaskan Malamute  ___Cone Degeneration - cd(m) test - $160
American Eskimo Dog  ___Primary Lens Luxation - PLL Test - $90 ($72 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
American Hairless (Rat) Terrier  ___Primary Lens Luxation - PLL Test - $90
American Pit Bull Terrier  ___Cone Rod Dystrophy (crd2) - crd2 Test - $120
   ___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia (NCL-A) - $150
American Staffordshire Terrier  ___Neuronal Ceroid Lipofuscinosis - Cerebellar Ataxia (NCL-A) - $150
Australian Cattle Dog  ___Primary Lens Luxation - PLL Test - $90 ($72 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Australian Shepherd  ___Canine Multifocal Retinopathy - CMR1 test - $95 ($76 multiple tests/dog)
   ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Cone Degeneration (cdm) - cd(m) test - $160 ($128 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Australian Shepherd, Miniature  ___Canine Multifocal Retinopathy - CMR1 test - $95 ($76 multiple tests/dog)
   ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Cone Degeneration (cdm) - cd(m) test - $160 ($128 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Australian Shepherd, Toy  ___Canine Multifocal Retinopathy - CMR1 test - $95 ($76 multiple tests/dog)
   ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Cone Degeneration (cdm) - cd(m) test - $160 ($128 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Australian Stumpy Tail Cattle Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Basenji  ___Pyruvate Kinase Deficiency - PK test - $80 *
Beagle  ___Glaucoma - POA Glaucoma - $95
Bearded Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Boerboel  ___Canine Multifocal Retinopathy - CMR1 test - $95
Border Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Neuronal Ceroid Lipofuscinosis - CL Test - $95 ($76 multiple tests/dog) *
   ___Trapped Neutrophil Syndrome - TNS Test - $95 ($76 multiple tests/dog)
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
Cane Corso  ___Canine Multifocal Retinopathy - CMR1 test - $95
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  ___Primary Lens Luxation - PLL Test - $90 ($72 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Chinese Foo Dog  ___Primary Lens Luxation - PLL Test - $90
Cockapoo  ___Phosphofructokinase Deficiency - PFK test - $80 *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Cocker Spaniel (American)  ___Phosphofructokinase Deficiency - PFK test - $80 *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $180 ($144 multiple tests/dog)
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 *
Giant Schnauzer  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Glen of Imaal Terrier  ___Cone Rod Dystrophy (crd3) - crd3 Test - $120
Golden Retriever  ___Ichthyosis - Ichthyosis - $120 *
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($80 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Goldendoodle  ___Ichthyosis - Ichthyosis - $120 *
   ___Improper Coat - Improper Coat Test - $80
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($80 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Great Pyrenees  ___Canine Multifocal Retinopathy - CMR1 test - $95
Greyhound  ___Neuropathy - NDRG1 Test - $95
Hokkaido dog  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $135 *
Irish Red & White Setter  ___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 ($105 multiple tests/dog) *
   ___Progressive Retinal Atrophy - rcd1 test for PRA - $120 ($95 multiple tests/dog) *
Irish Setter  ___Canine Leukocyte Adhesion Deficiency - CLAD test - $135 ($105 multiple tests/dog) *
   ___Progressive Retinal Atrophy - rcd1 test for PRA - $120 ($95 multiple tests/dog) *
Jack Russell Terrier  ___Primary Lens Luxation - PLL Test - $90
Jagt Terrier  ___Primary Lens Luxation - PLL Test - $90
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  ___Ichthyosis - Ichthyosis - $120 *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 multiple tests/dog)
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($80 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Labradoodle  ___Improper Coat - Improper Coat Test - $80
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $80 *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Labradoodle Goldendoodle Cross  ___Ichthyosis - Ichthyosis - $120 *
   ___Improper Coat - Improper Coat Test - $80
   ___Narcolepsy - NARC test - $130 ($104 multiple tests/dog) *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $80 *
   ___Progressive Retinal Atrophy - GR_PRA1 Test - $100 ($80 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Labradoodle, Australian  ___Improper Coat - Improper Coat Test - $80
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 multiple tests/dog)
   ___Phosphofructokinase Deficiency - PFK test - $80 *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Labrador Retriever  ___Narcolepsy - NARC test - $130 ($104 multiple tests/dog) *
   ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($120 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Lagotto Romagnolo  ___Benign Familial Juvenile Epilepsy - BFJE test - $95
   ___Improper Coat - Improper Coat Test - $80
Lakeland Terrier  ___Primary Lens Luxation - PLL Test - $90
Lancashire Heeler  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Primary Lens Luxation - PLL Test - $90 ($72 multiple tests/dog)
Lapponian Herder  ___Canine Multifocal Retinopathy - CMR3 test - $95
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Lucas Terrier  ___Primary Lens Luxation - PLL Test - $90
Markiesje  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Miniature American Shepherd  ___Canine Multifocal Retinopathy - CMR1 test - $95 ($76 multiple tests/dog)
   ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Cone Degeneration (cdm) - cd(m) test - $160 ($128 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Miniature Bull Terrier  ___Primary Lens Luxation - PLL Test - $90
Miniature Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Miniature Schnauzer  ___Progressive Retinal Atrophy - Type A test for PRA - $160 *
Moyen Poodle (Klein Poodle)  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Newfoundland  ___Cystinuria - cystinuria test - $80 *
Norwegian Elkhound  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Norwich Terrier  ___Primary Lens Luxation - PLL Test - $90
Nova Scotia Duck Tolling Retriever  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 multiple tests/dog) *
Old English Mastiff  ___Canine Multifocal Retinopathy - CMR1 test - $95
   ___Progressive Retinal Atrophy - Dominant test for PRA - $120
Papillon  ___Progressive Retinal Atrophy - Pap_PRA1 - $120
Parson Russell Terrier  ___Primary Lens Luxation - PLL Test - $90
Patterdale Terrier  ___Primary Lens Luxation - PLL Test - $90
Perro de Presa Canario  ___Canine Multifocal Retinopathy - CMR1 test - $95
Phalene  ___Progressive Retinal Atrophy - Pap_PRA1 - $120
Portuguese Water Dog  ___Improper Coat - Improper Coat Test - $80
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Pug  ___Primary Lens Luxation - PLL Test - $90
Rat Terrier  ___Primary Lens Luxation - PLL Test - $90
Rough Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $180 ($144 multiple tests/dog)
Russell Terrier  ___Primary Lens Luxation - PLL Test - $90
Samoyed  ___OculoSkeletal Dysplasia - Inherited RD/OSD - $160 ($128 multiple tests/dog)
   ___Progressive Retinal Atrophy - XL test for PRA - $150 ($120 multiple tests/dog) *
Schipperke  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Sealyham Terrier  ___Primary Lens Luxation - PLL Test - $90
Shetland Sheepdog  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Siberian Husky  ___Progressive Retinal Atrophy - XL test for PRA - $150 *
Silken Windhound  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Silky Terrier  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Sloughi  ___Progressive Retinal Atrophy - Sloughi test for PRA - $80
Smooth Collie  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 ($144 multiple tests/dog) *
   ___Progressive Retinal Atrophy - Rod-Cone Dysplasia Type 2 - $180 ($144 multiple tests/dog)
Spanish Water Dog  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Standard Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Swedish Lapphund  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Teddy Roosevelt Terrier  ___Primary Lens Luxation - PLL Test - $90
Tenterfield Terrier  ___Primary Lens Luxation - PLL Test - $90
Tibetan Terrier  ___Primary Lens Luxation - PLL Test - $90
Toy Fox Terrier  ___Primary Lens Luxation - PLL Test - $90
Toy Poodle  ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 *
Volpino Italiano  ___Primary Lens Luxation - PLL Test - $90
Welsh Terrier  ___Primary Lens Luxation - PLL Test - $90
Whippet, Longhaired  ___Collie Eye Anomaly/Choroidal Hypoplasia - CEA/CH test - $180 *
Wire Fox Terrier  ___Primary Lens Luxation - PLL Test - $90
Yorkshire Terrier  ___Primary Lens Luxation - PLL Test - $90 ($72 multiple tests/dog)
   ___Progressive Retinal Atrophy - prcd Mutation Test for PRA - $195 ($156 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 - Nova Scotia Duck Tolling Retriever - Old English Mastiff - 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
Nova Scotia Duck Tolling Retriever -- $7.50/test
Old English Mastiff -- $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.