CANINE DNA RESEARCH – Chinese Shar-Pei

Individual Dog Information - Update

code:___________________

Blood – Tissue – other _______________________

Registered Name _________________________________ Call name _________________

AKC# ________________ Birth Date _____________ Male / Female - - Intact / Neutered

Date Original Sample Submitted: (month/year): ____________________

Sample submitted for which research project? _____________________________________________

Owner: name ___________________________ Alternate _______________________

address _________________________ Contact ________________________

__________________________ ________________________

phone (day) ______________________ ________________________

phone (eve) ______________________ ________________________

fax __________________________ ________________________

e-mail ___________________________ ________________________

Date of Death ____________________________________

Cause of Death ___________________________________

Results of Necropsy __________________________________________

Positive for amyloid kidneys ___________ liver ______________ other ____________________

Negative for amyloid kidneys ____________ liver ______________ other ___________________

If available please attach Pathologist Report.

I submit this updated individual dog report for the purpose of DNA research; I understand that the identity of dogs and owners participating in the research will not be revealed; and I have supplied complete and accurate information, to the best of my knowledge.

Signed: ______________________________________ date __________________