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 Institute for Genetic Disease Control in
Animals |
Nonprofit & Tax-exemptGDC
PO Box 177
Warner, NH 03278
Telephone: 603-456-2350
Toll-Free: FAX: 603-456-2286
EMAIL:
gdc@conknet.com
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FOR GDC USE:
Ck. No.
Dog No.
A:
E: |
APPLICATION - RADIOGRAPHIC EVALUATION and
REGISTRATION
| For OWNER/AGENT to fill out |
| Owner Name: |
Co-Owner Name: |
| Address: |
City: |
State: |
Zip: |
| Breed: |
Sex M____(____N/S____) F____ |
Weight: |
Height: |
| Registered Name of Dog: |
Call Name: |
| Birth Date: |
Reg. No. (AKC, other) |
No. Dogs in Litter: |
| Sire's Reg. Name: |
Reg. No. |
| Dam's Reg. Name: |
Reg. No. |
| For VETERINARIAN to fill out: |
| IDENTIFIED BY: indicate one |
Tattoo# |
Microchip# |
DNA |
Coat Marking |
Owner, only |
| Site(s) To Be Evaluated |
Date/Radiograph |
Clinical Status |
Type of Restraint Used |
| Pelvis:-- Hip Dysplasia _____ |
. |
No Clinical Signs ________ |
Physical Only _____ |
| -- --Legg-Perthes _____ |
. |
Abnormal gait ________ |
Sedative Type _____ |
| -- --Stifles _____ |
. |
Lame ________ |
General anesthetic type _____ |
| Elbows: _____ |
. |
Can the patella be luxated YES____ NO ____ |
. |
| Shoulders: _____ |
. |
medial R_____ L_____ or lateral R_____ L_____ |
. |
| Hocks: _____ |
. |
Other Comments: |
|
| Skull: _____ |
. |
. |
|
| CLINIC/HOSPITAL |
Phone |
Fax |
| Address: |
City: |
State: |
Zip: |
| Signature of Veterinarian: |
Date: |
| Printed Name of Veterinarian: |
| For OWNER/AGENT to fill out |
A refund will be issued for any evaluations
showing known or suspected genetic disease. In this event, I prefer to (check one) receive
a refund check _____ or donate it to the GDC _____
| FEES FOR THIS APPLICATION |
|
| $20 _________ |
For entering a dog in the Registry
& Evaluation & Certification of one normal site (see appropriate GDC Instruction
card for breeds with specific databases) |
| $5 __________ |
For each additional sit evaluation
requested at the same time; $10 for additional site submitted separately |
| $50 _________ |
Maximum, for litter package of _____
siblings submitted together (No refunds for affected sites.) |
| $2 __________ |
each for registering normal report
from another agreed registry named _____________________: no charge for affected |
| $2 __________ |
for FAX report sent to the following
FAX number : (_____) _____ - __________ |
| TOTAL $ __________ |
Check enclosed for this amount:
$_________ |
OWNER: I Hereby certify that the radiograph submitted
is of the dog described on this application. I am aware that the radiograph will be
retained for the records of the Institute for Genetic Disease Control in Animals. I
authorize the GDC to release the radiographic evaluation to my breed club, responsible
breeders, owners, prospective owners, and investigators.
Registered Name of Dog (from first
page of this form):__________________________________________
Signature of owner or authorized agent: _______________________
Date: ______________________________
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