DNA Testing Submission Form
Section I: Service Requested
q Parentage Evaluation
q DNA Profiling
q Inherited Trait/Disease Test (Specify:)_ _______________________________
Section II: Submitter's Information
Submitter's Name: (please print legibly)___________________________________________________________________________
Address:_ _______________________________________________________________________________________________
City:________________________________________________________________ State:_________ Zip:______________
Phone #1: __________________________________________ Phone #2:_ _________________________________________
Fax #:_ ____________________________________________ Email:_____________________________________________
Section III: Tested Animal's Information
SAMPLE #1
If there are additional animals to be tested, please fill out Section VI on the back.
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
SAMPLE #2
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
Section IV: Payment Information
If paying by check, please make payable to DDC Veterinary.
Amount: $________________________ Payment by: q Enclosed Check or Money Order q Credit Card (information below)
q MasterCard q VISA
Card #:_ __________________________ q Discover
Expiration Date:_________ /_________
Name: (exactly as it appears on card)______________________________________________________________________________
Billing Address:_ _________________________________________________________________________________________
City:________________________________________________________________ Section V: Statement of Agreement
I hereby certify that the information appearing on this form is correct and true to the best of my knowledge. I hereby affirm that the DNA sample was collected and
labeled properly. I understand that all test results and documentation will be provided to only me, unless otherwise specified.
Signature: X________________________________________________________________ Date:______ /_______/______
www.vetdnacenter.com
One DDC Way Fairfield, OH 45014 U.S.A.
1-800-625-0874
101008-RS
Signature of Cardholder: X____________________________________________________ Date:______ /_______/______
ATS-4000-VT
State:_________ Zip:______________
DNA Testing Submission Form
Section VI: Additional Tested Animal's Information
SAMPLE #3
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
SAMPLE #4
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
SAMPLE #5
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
SAMPLE #6
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
SAMPLE #7
Please check one: (for Parentage Evaluation ONLY)
q Sire
q Dam
q Progeny
Call Name: (please print legibly)_ ____________________________________________ Sex: q Male q Female
Date of Birth:_ _____ /_______ /_ _____ Breed:____________________________ Coat Color:_______________________
Registered Name:______________________________________________________ Registry:_________________________
Registration #: ______________________________________ Microchip / Tattoo:___________________________________
Markings:_ ______________________________________________________________________________________________
Reason for testing:_ _______________________________________________________________________________________
www.vetdnacenter.com
One DDC Way Fairfield, OH 45014 U.S.A.
1-800-625-0874