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