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CANINE DACHSHUND Miniature Wirehair Submission Form • Laboratory of Veterinary Genetics • DNA Analysis DIAGNOSTIC SERVICES www.medvet.umontreal.ca Direct: 450-778-8151 Tel: 450-773-8521 ext. 8243 or 514-343-6111 ext. 8243 Fax: 450-778-8107 Send Samples to: Sample Reception, CDEVQ DiagnosVc Services Faculty of Veterinary Medicine University of Montreal, 3220 Sico^e St. Saint-Hyacinthe, Quebec, Canada J2S 2M2 ANIMAL / OWNER INFORMATION Direct Inquiries to : Dr David Silversides 450-‐773-‐8521 ext. 8464 [email protected] Ms Isabelle Daneau 450-773-8521 ext. 8226 [email protected] VETERINARIAN NFORMATION Name of animal:________________________________________ Veterinarian:______________________________________ Breed:____________________________ Age: _______________ Veterinary Clinic:___________________________________ Sex: Address:__________________________________________ F M Colour:____________________ Identification:__________________________________________ __________________________________________________ Dossier No:____________________________________________ Tel:__________________ Fax:______________________ Owner Name:__________________________________________ e-mail:___________________________________________ Address:______________________________________________ _____________________________________________________ Tel:__________________________________________________ e-mail: ______________________________________________ Submission Date:_______________________________ Sample Type submitted: Buccal Swab Sample (4X) Bill To: Client SAMPLE INFORMATION Veterinarian Small Animal Hospital (CHUV) Blood (EDTA) 2 to 5 ml DNA ANALYSES FOR DACHSHUND Miniature Wirehair : Please check off test(s) you wish to have done. Epilepsy (Lafora) (M408) Mucopolysaccharidosis IIIa (MPS IIIa) (M517) Narcolepsy (Dachshund type) (M513) Neuronal Ceroid Lipofuscinosis 1 (NCL-1) (M456) Neuronal Ceroid Lipofuscinosis 2 (NCL-2) (M412) Osteogenesis Imperfecta (Dachshund type) (M548) PRA-CRD4/Cord1 (M540) PRA-CRD-SWD (M422) Cream (Agouti/dominant yellow) (M419) Dapple (M414) Dilution (locus D) (M427) Long Hair (locus L) (M537) Recessive Red (E locus) (M430) Genotype, parentage (G401) Other :________________________________________ Send completed submission form and samples to: Sample Reception, CDEVQ, Diagnostic Services, Faculty of Veterinary Medicine, University of Montreal, 3220 Sico^e Street, Saint-Hyacinthe, Quebec, Canada J2S 2M2 www.labgenvet.ca
