University of Pennsylvania School of Veterinary   University of Pennsylvania School of Veterinary Medicine Section of Medical Genetics
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.

Urine Cystinuria Screening Submission Form

Sample Submitted:
Urine 2-5mls (required)       Other:
Collection Date:       Shipping Date:

Send Report To:
Veterinarian       Owner/Agent       Both Veterinarian and Owner/Agent

Veterinarian Information: (if clinic submits samples)
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:
Tom/Sire Name:
 Tom/Sire Registration Number:
 Queen/Dam Name:
 Queen/Dam Registration Number:

Reason for Testing: (check all that apply)
General Screening
Breeding
Suspicious Clinical Signs (explain below)
 Relative known to be an Affected (explain below)
Relative known to be a Carrier (explain below)
Other (explain below)

Comments: (attach another sheet with lab test results if necessary)
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."