Breed: Welsh Springer Spaniel Litter ID code: ______________________

Sample submitted for which research project? Data Bank

Sample submission date: _______________________

Registered name: ______________________________

AKC# ________________________________________

Call name: ____________________________________ M -F

 Birth date:____________________

Owner: Name: __________________________ Alternate _________________________

Address:_______________________________              _________________________

_______________________________________             _________________________

phone (day) _____________________________            __________________________

phone (evening) __________________________            __________________________

fax ____________________________________             _________________________

email ___________________________________           __________________________

Does this dog exhibit any of the following conditions? (Attach history for any Yes question)

Y - N Allergies                                Y - N Digestive difficulties

Y - N Arthritis                                 Y - N Heart Problems

Y - N Autoimmune Disorders           Y - N Hernia (where:_____________________)

Y - N Cancer/Tumors                      Y - N Reproductive Disorders

Y - N Cataracts/ Eye problems        Y - N Seizures

Y - N Deafness/Hearing Impaired     Y - N Skin/Coat Problems

Y - N Bite or tooth abnormalites      Y - N Skeletal Abnormalities (hip dysplasia, etc.)

Y - N Temperment problems (shy, aggressive, etc.)

Other (please list)

Testing done on this dog:

OFA/Penn hip Y - N age at test:___________ Result:____________ #_______________

CERF Y - N age last tested:________ Result:____________ #_______________

Thyroid Y - N age last tested:________ Result:_____________________________

Thyroid Autoantibody age last tested:___________ Result:___________________

Please list any titles on this dog (championships, obedience, field work)

Please circle your response to the following:

-I am/ am not willing to provide additional blood samples if needed for research.

-I will/ will not consider the donation of a tissue sample (spleen, kidney, or liver) upon the death of this dog, and will discuss this decision with my veterinarian so that a notation is placed in my file.

I submit this sample and pedigree for the purpose of DNA research; I understand that the identity of the 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________________________