Border Collie Genetics Survey
Owner Name __________________________________________________________________________
Address _____________________________________________________________________________
__________________________________________________________________________________
Phone __________________________ Email ______________________________________________
Dog Name ____________________________________________________________________________
Dog Registration Number _________________________________________________________________
(if known)
Date of Birth ___________________________ Breeder ________________________________________
Sire Name _____________________________________________________________________________
(if known)
Dam Name ____________________________________________________________________________
(if known)
Gender Male Female
Has this dog exhibited Seizures? No Yes
If known, what type of seizure?_____________________________________________________________________________
______________________________________________________________________________________________________
At what age did the dog have his/her first seizure? ______________________________________________________________
Has this dog been diagnosed with Epilepsy: No Yes
Have any relatives been diagnosed with Epilepsy: No Yes
Has this dog suffered from any other health problems? ____________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please return this form with the blood sample or mail to:
Dog DNA Research
Veterinary Genetics Laboratory
One Shields Avenue
University of California
Davis, CA 95616-8744
Please also send a copy of the pedigree and relevant medical records, if available.
Questions? Contact Katy Robertson at 530-752-3864 or katy@ucdavis.edu