Make your own free website on Tripod.com
 
 
 
 

Home
 

Policy Statement
Studies
Articles
Forms list
Join Us !

 
 
 
 

Breeding for a

pals.JPG (3490 bytes)

healthy future

 
Institute for Genetic Disease Control in Animals
Nonprofit & Tax-exempt
P.O. Box 222, Davis, CA 95617
Phone/Fax (530) 756-6773
 
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:
 
Phone:
 
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: ________