2009

Northeast Ohio Mastiff Picnic

&

Ohio Valley Mastiff Club

Cystinuria CLINIC Submission Form

*$35 Cystinuria Urine Screening Tests

PLEASE NOTE: RESULTS MAY TAKE LONGER THAN NORMAL DUE TO THE

LARGE QUANTITY OF TESTS THAT ARE BEING SUBMITTED TOGETHER.

Owner’s Name:  
 
Co-Owner’s Name:  
 
Co-Owner’s Name:  
 
Street:  
 
City:  State:  Zip: 
 
Home Phone#:   Cell Phone:  
 
Fax#:  E-Mail: 
 
Breed: MASTIFF Date of Birth: // (mm/dd/yyyy) 
 
Dog's full registered name: 
 
Call Name:  Registration #: 
 
 American Kennel Club   Canadian Kennel Club   OTHER:  
 
AKC DNA #:  Microchip:  Tattoo:  
 
Sex:  Male  Female  Neutered:  Yes  No
 
Coat Color:  Fawn  Apricot  Fawn Brindle  Apricot Brindle
 
Sire Name:  
 
Sire's AKC: 
 
Dam’s Name:   
 
Dam's AKC: 
 
 
 
*Clinic price is $35 which includes S&H. The normal individual mail in price is $40 plus S&H    
 
Cystinuria page 2 of 2
 
 
Dog's full registered name: 
 
Owner’s Name:  
 
Date of urine collection: // (mm/dd/yyyy)
 
Urine sample was collected how many hours after dog’s last meal?  hours
 
Dog's diet: 
 
Has your dog had a previous cystinuria urine test? Yes No
 
Results:  UPenn Cystinuria # (if known): 
 
Any previous health problems including urinary tract infections? Yes No
 
Current Medications (Please list all):
 
 
Reason's for testing: (check all appropriate items)
 
  MCOA Health Award  urinary tract infections   
  General screening  difficulty urinating
  Showing   blood in urine
  Breeding  crystals in urine
  Suspicious clinical signs  calculi (stones)
  Relative known to be affected  Relationship:   
 
 Number of submission forms  Number of urine samples
 
2009 Northeast Ohio Mastiff Picnic & Ohio Valley Mastiff Club
“Cystinuria Clinic”
 
Cystinuria Clinic Fee:  *$35 per sample (special clinic price)

CASH OR CHECK ONLY!
Make check payable to "Kim Fish"

If you have an affected dog, please inform UPenn directly and send them information on the diagnosis of Cystinuria (e.g., stone analysis). All information will be kept strictly confidential.

PLEASE NOTE: UPenn needs blood, urine, 5 generation pedigree, DNA Consent Form and Questionnaire from all Mastiffs that test positive as well as from their close relatives (vertical & horizontal). UPenn’s Cystinuria research is dependent on DNA (blood) and accurate data.

Cystinuria testing is FREE to Mastiffs that have previously tested Positive (C+) and have submitted blood samples to UPENN to be included in their Cystinuria Research Study.

Please participate in Cystinuria Research!