CANINE BERNESE MOUNTAIN DOG

CANINE
BERNESE MOUNTAIN DOG
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 BERMESE MOUNTAIN DOG : Please check off test(s) you wish to have done.
Degenerative Myelopathy (SOD1) (M416)
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