Research

Thank you for participating in this study. Please print this form,  fill it in completely and send it with the blood.

Name: ______________________________________
Address:____________________________________
Phone:___________________Fax:_________________Email:_________________

Dog: Registered Name:__________________________________
Registered No.:_____________________________
Birthdate: ____/____/____
Call Name:_______________________
Breed:___________________________
Sex:____________

Sire: Registered Name:____________________________________
Registered No.:______________________________
Call Name:________________________

Dam: Registered Name:___________________________________
Registered No.:______________________________
Call Name:________________________

I certify that I am the owner or authorized agent of the owner of the above dog, and that the accompanying blood sample is correctly identified by the above information.

I realize that, because this blood is to be used for scientific research, test results or other information will not be available to me until the gene defect and mutation are identified, and a mutation based test is developed.

Signed:_________________________________________Date:____/____/____

This blood will be assigned a coded number to keep the source confidential. Please send samples by first class, priority or express delivery in a well padded shipping container to:

Ms. Susan Pearce-Kelling/Cataract Study
OptiGen, LLC
Cornell Business and Technology Park
767 Warren Road, Suite 300
Ithaca, NY 14853

If you have any questions, please call (607-257-0301) or e-mail (suepk@optigen.com) Ms. Pearce-Kelling