Sample #:____________ Date:_________________
FOR OFFICE USE ONLY
If
not
submitted by the owner,
please enter account # to be used: ________________________
Equine Test Submission Form
Name:____________________________________ Business Name:_________________________________________
Address: __________________________________________________________________________________________
City: _____________________________________ State: ______ Zip Code: ___________ Country:_______________
Phone #: ___________________ Fax #: ____________________E-mail: _____________________________________
Sample Information
_____________________________________________________________Registration #: ___________________
Name:
Breed: __________________________________________________ Color: ____________________________________
Gender: _________________________________________ Year of Birth: _____________________________________
Parents of Horse
(not required)
Sire’s Name: _______________________________________________________________________________________
Registration: ________________ Breed: ________________________________ Color: __________________________
Dam’s Name: ______________________________________________________________________________________
Registration: ________________Breed: ________________________________ Color: __________________________
TEST FOR COAT COLOR
TEST FOR GENETIC DISORDERS
Leopard Print (LP) Appaloosa
Hyperkalemic Periodic Paralysis (HYPP)
Tobiano
Hereditary Equine Regional Dermal Asthenia (HERDA)
Polysaccharide Storage Myopathy – Type 1 (PSSM1)
Lethal White/Frame Overo (LWO)
Splash White (SW1, SW2, SW3)
Malignant Hyperthermia (MH)
Sabino1
Glycogen Branching Enzyme Deficiency (GBED)
Red/Black Factor
Junctional Epidermolysis Bullosa (JEB1, JEB2)
Agouti (Bay)
Severe Combined Immunodeficiency (SCID)
Cream Dilution
Cerebellar Abiotrophy (CA)
Silver Dilution
Lavender Foal Syndrome (LFS)
Champagne Dilution
Congenital Stationary Night Blindness (CSNB)
Pearl Dilution
Warmblood Fragile Foal Syndrome (WFFS)
DUN (40.00)
Fatal Foal Immunodeficiency (FIS)
Gray
Arabian Horse Panel (
SCID, CA, LF
)
($125.00)
Dominant White (W5, W10)
Arabian Horse Panel (
SCID, CA, LF, Gray, Red/Black, Agouti
)
($155.00)
Color Panel
Horse Panel (
($95.00)
FIS, PSSM1, WFFS, JEB1, JEB2
)
($95.00)
Quarter Horse Panel (
Red/Black, Agouti, Cream, Silver, Pearl, Champagne
HYPP, HERDA, GBED, PSSM, MH
)
($95.00)
Pattern Panel
($95.00)
TEST FOR DNA PROFILE
Appaloosa, Tobiano, LWO, Splash White, Sabino
Full Color & Pattern Panel
($150.00)
DNA Profile (ISAG+)
Amount: _________ Check#______ Money Order Credit Card Request a PayPal Invoice
Payment
Pre-pay Via PayPal (PayPal@animalgenetics.us) Date Payment Sent: ________ Transaction Number:_______________
Credit Card Information
Print customer name:
Account #:
Exp. Date:
Signature of Cardholder:
Billing zip code (postal code):
3 or 4 digit Security Code #::
Test results and invoices are sent via email as a PDF. Please check here to have results sent via US Mail.
Instructions:
Pull 30-40 mane or tail hairs with roots attached. Place hairs into a plastic zip-lock bag. Only one sample per horse is required to run multiple tests. Label bag with the horse’s name as
indicated on this form. Include payment information for the appropriate amount and send samples to the address below.
By submitting this form with your sample you agree that Animal Genetics Inc. will not be held accountable for any incidental or consequential damages of any kind. Furthermore, Animal
Genetics Inc. retains full ownership of the sample submitted. All test results are confidential. Access to test results is limited to the individuals listed on the account.
Animal Genetics Inc. 1336 Timberlane Road, Tallahassee, FL 32312 Toll Free 866-922-6436 850-386-2973