CYSTINURIA SAMPLE SUBMISSION FORM
Mark one with an X:
Owner (___) Breeder (___) Veterinarian (___)
Name: _________________________________
Street: _________________________________
City: ___________________ State:_____ Zip:_______
Date of urine collection: _______________
Dog's name: _____________________________
(If a litter is being tested, state "litter" beside dog's name
and list name,
age, and gender of each puppy and ID on
sample submitted on the back of this page.)
AKC#: __________________________Chip/Tatoo: __________________________
Breed: __________________________Age: ___________________
Sex:Male(___)Female(___)Neutered/Spayed:Yes(___)No(___)
Sire: ___________________________Sire's AKC: ___________________________
Dam: ____________________________Dam's AKC: ____________________________
Reasons for testing: (mark all appropriate items with an X)
general screening (___)
suspicious clinical signs (___)
breeding (___)
showing (___)
puppy (at least four weeks old) (___)
relative known to be affected (specify who) (___)
difficulty urinating (___)
blood in urine (___)
crystals in urine (___)
calculi (stones) (___)
Number of submission forms (____)Number of urine samples (____)
Costs:(please make check payable to "Trustees,Univ. of Penn,
Dr.
Giger") $18 per dog, or $10 per 4-12 week old puppy only if more
than 5 puppies are tested
Check in the amount of $__________
Shipping Instructions: Liquid urine in tube with ice pack,
overnight mail.
Dr. John Melniczek / Cystinuria
Veterinary Hospital, Room 4020
University of Pennsylvania
3900 Delancey Street
Philadelphia, PA 19104-6010
Phone: 215-898-8078 Fax: 215-573-2162
If you have an affected dog, please inform us by sending this form
along with any information on the diagnosis of Cystinuria (e.g.,
stone analysis).
