Institute for Genetic Disease Control in Animals
Nonprofit & Tax-exempt
P.O. Box 222, Davis, CA 95617
Phone/Fax (530) 756-6773
FOR GDC USE:

Ck. No.

Dog No.

A:

E:

APPLICATION - RADIOGRAPHIC EVALUATION and REGISTRATION

For OWNER/AGENT to fill out
Owner Name: Co-Owner Name:
Address: City: State: Zip:
Phone:
Breed: Sex M____(____N/S____) F____ Weight: Height:
Registered Name of Dog: Call Name:
Birth Date: Reg. No. (AKC, other) No. Dogs in Litter:
Sire's Reg. Name: Reg. No.
Dam's Reg. Name: Reg. No.
For VETERINARIAN to fill out:
IDENTIFIED BY: indicate one Tattoo# Microchip# DNA Coat Marking Owner, only
Site(s) To Be Evaluated Date/Radiograph Clinical Status Type of Restraint Used
Pelvis:-- Hip Dysplasia _____ . No Clinical Signs ________ Physical Only _____
-- --Legg-Perthes _____ . Abnormal gait ________ Sedative Type _____
-- --Stifles _____ . Lame ________ General anesthetic type _____
Elbows: _____ . Can the patella be luxated YES____ NO ____ .
Shoulders: _____ . medial R_____ L_____ or lateral R_____ L_____ .
Hocks: _____ . Other Comments:  
Skull: _____ . .  
CLINIC/HOSPITAL Phone Fax
Address: City: State: Zip:
Signature of Veterinarian: Date:
Printed Name of Veterinarian:
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 (check one) receive a refund check _____ or donate it to the GDC _____

FEES FOR THIS APPLICATION  
$20 _________ For entering a dog in the Registry & Evaluation & Certification of one normal site (see appropriate GDC Instruction card for breeds with specific databases)
$5 __________ For each additional sit 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: $_________

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: ______________________________