Form 4 for Yorkie Encephalitis


If you have a healthy Yorkie and are interested in contributing to our research efforts, please consider having your pet donate a DNA sample. We are always looking for healthy control dogs and these samples are critical to the research efforts. Ideally healthy control dogs should be between 5-12 years old but samples will be accepted from younger and older dogs as well. If you are interested, please see the sample collection instructions below and fill out and email the necessary information to rbarber1@uga.edu.

INSTRUCTIONS FOR SAMPLE COLLECTION AND SHIPMENT:
Your pet's DNA can be collected in one of two ways: from a small blood sample collected by your veterinarian (preferred) or from a cheek swab.

Blood sample
Have your veterinarian collect and ship your pet's blood to us. We need 2-3ml of blood in an EDTA tube. Blood can be stored in the refrigerator for up to 1 week prior to shipment.

Cheek swab
If you would prefer to get a cheek swab for your pet, please contact Dr. Barber (rbarber1@uga.edu) to acquire the necessary supplies and instructions.

Samples can be shipped at room temperature to:
Renee Barber
Department of Small Animal Medicine and Surgery
University of Georgia College of Veterinary Medicine
501 DW Brooks Drive
Athens, GA 30602
rbarber1@uga.edu.

Please include complete medical records for the animal, including vaccination dates and manufacturers. Individual veterinarians will be responsible for obtaining permission to use the pet's tissues for genetics research. If needed, veterinarians can contact Dr. Renee Barber if they would like help developing a release form for owners to sign.

Press the 'send' button when you are done. For correction before sending, press 'oops' If the form isn't working, please just e-mail Us the information.

(Please don't use a P.O. Box for addresses, we need an actual location)




Owner Information:
Your Name:

Your address: City:

State: Zip Code:

Home phone: Work phone:

Cell phone: Email:

May we contact you for additional information if necessary?
Yes No
If yes, what do you prefer?
E-mail Phone

Pet Information:
Registered Name: Call Name:
AKC Number: Date of Birth:
Sex: Status:(Spayed, Neutered, Unaltered)
Height: Weight:
Is pedigree available and included with form? Yes No
If no: Can you mail this to Dr. Barber
Will Mail Will not Mail

Date of last Vacination: Administered Vacinations:

Vet Contact Info:
Name:
address:
City: State: Zip:

Please provide a brief medical history (including when signs / symptoms of encephalitis first began, what the signs / symptoms were, how the signs / symptoms have progressed over time, what medications have been administered, did the signs / symptoms improve or worsen with medication):


Please describe any other known medical conditions:
Current medications (name, dose, how often they are administered):


Please describe any other known medical conditions:
Current medications (name, dose, how often they are administered):



Additional Comments:



Press send only once!




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