Factor XI Deficiency (Kerry Blue Terrier)
DNA Test Submission Form
Contact Information
First name: ________________________
Last name: ___________________
Veterinarian
Address: ________________________________
Owner’s agent
City: ________________ State/Province: ____
Zip: _________ Country: __________
Home phone: ______________________
Business phone: _____________________
Fax: ___________________
Email: ______________________________________
Owner Information (if different from above)
First name: ________________________
Last name: ___________________
Address: _____________________________________
City: ________________ State: ____
Zip: ___________________ Country: __________
Phone: ____________________
Fax: _______________
Email: _________________________________
Animal Information
Official name:________________________________________
Call name: _____________________________
Date of birth:_________________ (mm/dd/yy)
Registration #: ________________ AKC Other: __________
Breed: Kerry Blue Terrier Sex: Male Female Neutered Intact
Sire’s name _________________________ Sire’s registration #:
________________
Dam’s name ________________________ Dam’ registration #: __________________
Sample Information
Date of sample collection: ___________________ (mm/dd/yy)
Sample type: 1-2 mL EDTA blood or 2-3 cheek swabs (rotate brush inside cheek
10 times)
Reason for testing: (Check all that apply)
__ General screening Breeding Suspicious clinical signs (bleeding tendency)
__ Relative known to be affected/carrier
__ Abnormal (PTT or ACT) coagulation test results (include test results)
__ Other: ______________________________
Has this dog experienced any excessive bleeding after:
nail clip? Yes or No
Surgery or trauma? Yes or No
If yes to either question, please provide additional information:___________________________________________
Please label samples with the animal’s call name and owner’s
last name. Include credit card information or a check payable to ‘Trustees,
University of Pennsylvania/Dr. Giger’.
Price: $50.00 per dog (through June 30, 2006) thereafter $75.
Note the DNA test will be free of charge for dogs showing a bleeding tendency
or prolonged clotting time as long as we receive an EDTA and frozen citrated
plasma sample until June 30, 2006. Questions please contact Dr. Giger.
All information will be kept strictly confidential. Results are available
3-4 weeks from receipt of samples, are kept confidentially, and will only
be sent to the person submitting the sample.
Ship to:
Dr. Urs Giger/ FXI KBT
Veterinary Hospital – Rm 4006
University of Pennsylvania
3900 Spruce Street
Philadelphia, PA 19104-6010penngen@vet.upenn.edu
Phone 215-898-8894/3375
Fax: 215-573-2162
http://www.vet.upenn.edu
University of Pennsylvania School of Veterinary Medicine
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