00000..........................
Nonprofit & Tax-exempt
P.O. Box 222, Davis, CA 95617
Phone/Fax (530) 756-6773
www.vetmed.ucdavis.edu/gdc/gdc.htm
2295761@mcimail.com 		FOR GDC USE:
Ck. No.
Dog No.
A:
E:

Application:  RADIOGRAPHIC EVALUATION and REGISTRATION [NOTE: Fee Change as of May 1, 2002]

For OWNER/AGENT to fill out

Owner Name:_______________________________________

Co-Owner Name:_____________________________________

 

 

Address:______________________________________

City:___________________________

State:____

Zip:_________

 

 

 

Phone:___________

Fax:___________

E-Mail:_____________________________________

Country__________

 

Breed:___________________________________________

Sex M____(____N/S____) F____

Weight:_______

Height:_______

 

Registered Name of Dog:__________________________________

Call Name:________________

 

Birth Date:____________

Registration Number (AKC, other)___________

Number of Dogs in Litter:______

 

Parents of dog being evaluated

Sire's Registered Name:_______________________________________

Registration Number:__________

Dam's Registered Name:_______________________________________

Registration Number:__________

For VETERINARIAN to fill out:

Dog Identified by:

Tattoo #:___________

Microchip #:___________

DNA:______

Coat Marking:______

Owner:______

 

Please Check Sites to be Evaluated by GDC Radiologists

Site

Date of Radiograph

Comments

Pelvis

:

:

Hip Dysplasia:

:

:For best results the dog must be sedated

Legg-Perthes:

:

:

Stifles:

:

Medial R___ L___ or Lateral R___ L___
Can the patella be luxated No____ Yes ____?

Elbows:

:

GDC requires two views--see instructions.

Shoulders:

:

:

Hocks:

:

:

Skull:

:

For Diagnosis of CMO

 

Clinical Status

No Clinical Signs:____

Abnormal Gait:____

Lame:___

Type of Restraint Used

General Anaesthic, Type______

Sedative, Type:_______

Physical Only:____

 

CLINIC/HOSPITAL

Name:

Street Address:

 

City:

Postal Code:

Country:

 

Phone:

Fax:

E-Mail:

 

Please print name of Veterinarian:________________________
Signature:________________________

Date________

For OWNER/AGENT to fill out

A refund will be issued for any evaluations showing known or suspected genetic disease. In this event, I prefer to make a tax deductable donation to the GDC _____ (GDC is a 501(c)3 corporation) or receive a refund check_____.

Fees: Registration and Evaluation  [Fee change as of May 1, 2002]                   

Hip Dysplasia Registry (Check one option below)

__ $20 Single reader evaluation

Registration and evaluation of hips for one dog; single reader evaluation

__ $30  Multiple reader evaluation

Registration and evaluation of hips for one dog; multiple readers evaluation

Elbow Dysplasia Registry (Check one option below)

__ $20 Single reader evaluation

Registration and evaluation of elbows (two views) for one dog; single reader evaluation

__ $25  Multiple reader evaluation

Registration and evaluation of elbows (two views) for one dog; multiple readers evaluation

Hips and Elbows combined (Check one option below)

__ $25 Single reader evaluation

Registration and evaluation of hips and elbows for one dog; single reader evaluation

__ $35  Multiple reader evaluation

Registration and evaluation of hips and elbows for one dog; multiple reader evaluation

Other Options

$5 ____

For each additional site evaluation requested at the same time; $10 for additional site submitted separately

$50 ____

Maximum, for litter package of _____ siblings submitted together (No refunds for affected sites.)

$2 ____

each for registering normal report from another agreed registry named _____________________: no charge for affected

$2 ____

for FAX report sent to the following FAX number : (_____) _____ - __________

TOTAL $ ________

Check enclosed for this amount: $_________  [US$ only, please]

OWNER: I Hereby certify that the radiograph submitted is of the dog described on this application. I am aware that the radiograph will be retained for the records of the Institute for Genetic Disease Control in Animals. I authorize the GDC to release the radiographic evaluation to my breed club, responsible breeders, owners, prospective owners, and investigators.
Registered Name of Dog (from first page of this form):__________________________________________

Signature of owner or authorized agent: _______________________ Date: ________                             Rev. 4/02