Orthopedic Foundation for Animals
Application for Spine Database

registered name
 registration no.                       AKC-CKC other
breed sex                                 color
tattoo, microchip, other, if any date of birth
registration number of sire registration number of dam
owner's name

 

 veterinarian's name or veterinary hospital

 
mailing address
 mailing address
city                                         state         zip city                                             state       zip
telephone number (    )  telephone number (    ) 

I hereby certify that the animal examined is the animal described on this application.  I understand that this information will be part of a confidential spine database maintained by OFA for research purpose only.

  Owners or agents signature

____________________________

date

______________________________

Cervical 

Thoracic 

Lumbar
  1 2 3 4 5 6 7 1 2 3 4 5 6 7 8 9 10 11 12 13 1 2 3 4 5 6 7

Hemivertebra

                                                      
Butterfly Vertebra                                                      
Block Vertebra                                                      
Transitional Vet.                                                      
Spina Bifida                                                      
Remarks:
_____Spondylosis

_____Other

____________________
G.G. Keller, D.V.M.,MS
Executive Director
Diplomate of A.C.V.R
Neurologic Signs:

Age of Onset
Diagnosis___________________________

______________________
Veterinarian's signature  Date
Orthopedic Foundation for Animals, 2300 E. Nifong Blvd. Columbia, MO 65201
Telephone Number (573) 442-0418    Fax (573)875-5073
A Not-For-Profit Organization