Metabolic Genetic Screening Submission Form


Send Samples to: Email: penngen@vet.upenn.edu Phone: (215) 898-3375/8894 Fax: (215) 573-2162	Dr. Giger/(state test requested) PennGen Testing Lab 3900 Spruce Street, Room 4013 Philadelphia, PA 19104-6010	Visit our Website @: www.vet.upenn.edu/penngen All information will be kept confidential.

Metabolic Genetic Screening Submission Form

Sample Submitted: (Mark as many as applicable)
Urine 2-5mls (required) Serum EDTA Whole Blood Other:
Collection Date: Shipping Date:

Veterinarian Information:
Name:	Hospital Name:
Address (line 1):	Phone:
Address (line 2):	Fax:
City:	Email:
State:	Zip Code:
Country:

Owner/Agent Information: (if different from above)
Name:	Hospital Name:
Address (line 1):	Phone:
Address (line 2):	Fax:
City:	Email:
State:	Zip Code:
Country:

Patient Information: (call name, species and breed required)
Patient's Official Name:	Call Name:	Age:
Species:	Breed:	Sex: M F	Neutered?: Yes No
AKC (yes/no or specify):	Registration Number:	Other Comments:

Clinical Information Required for Testing
History and Clinical Signs (onset, specific signs, physical examination):
CBC and Urinalysis Results:
Medication:
Special Diet:

Results will be available approximately 3-4 weeks from receipt of sample.

Please label all samples with animal’s call name and owner’s last name and date. Include credit card information below (credit card information needed: VISA/MasterCard, expiration date, name as it appears on the card, card number) or a check payable to "University of Pennsylvania Trustees/ Dr. Giger."