Institute For Genetic Disease Control ¨ Tel. 603/456-2350 FAX 456-2286

P.O. Box 177, Warner, NH 03278 ¨ http://www.vetmed.ucdavis.edu/gdc/gdc.htm

Tumor/Cancer Registration Form: Page 1 (of 2)

To register a cancer or tumor diagnosis for you dog you will need to submit a copy of the pathology report along with the following completed forms.

DO NOT SEND TISSUES TO GDC

Step 1 For Owner/Agent to fill out and sign:

Owner name__________________________________Co-owner____________________________________

Address ______________________________________Apt. #_______City ____________________________

State____Zip___________ Country_________ Tel.____/____________ FAX____/_____________

Registered name of dog _____________________________________________ Call name _______________

Registration number (AKC, other) _____________

Sex: rM rF r N/S Birth ___/______/_____ Death ____/______/____Weight_____Height_____

If dog has not been registered before with GDC, please include, or send later, a four-generation pedigree.

Please also complete the following, if dog has not been registered before with GDC:

Litter reg. no._______________ Number & sex in litter: # males________ # females_________

Breeder_____________________________________

Address ______________________________________Apt. #_______City ___________________________

State____Zip___________ Country_________

Sire's reg. name _____________________________________ Birth___/___/___Reg. no.________________

Owner (sire)________________________________

Address ______________________________________Apt. #_______City ___________________________

State____Zip___________ Country_________

Dam's reg. name _____________________________________ Birth_____/_____/____Reg. no.__________

Owner (dam)________________________________

Address ______________________________________Apt. #_______City ___________________________

State____Zip___________ Country_________

OWNER: I hereby certify that pathology report submitted is of the dog described on this application.

I understand that the diagnosis and other information on this sheet will be retained in the GDC open Tumor Registry or Research Database.

I agree to allow GDC to release the data in the open registry to responsible breeders, owners, prospective owners and investigators. I agree to allow GDC to release the data in the research data base only to authorized investigators.

Signature of owner/authorized agent _____________________________________________Date___/____/____

Fees:

GDC tumor registration fee: $15 per dog, first GDC registration; $10 per dog if previously registered

Make check payable to "GDC"

Tumor/Cancer Registration Form: Page 2 (of 2)

Step 2 For Veterinarian to fill out and sign:

Please complete following form for submission with the Owner's form.

Dog Name_________________________Owner Name______________________________________________

Dog Identified by: Microchip#________Tattoo________DNA___________Owner's Statement________________

Date Specimen Taken:___/___/___ r Biopsy r Necropsy

Location of sample(s)_________________________________________________________________________

Comment:_________________________________________________________________________________

Clinic/Hospital___________________________________Phone____________________Fax________________

Address______________________________________City________________________State_____Zip_______

Please Print Name of Veterinarian:_______________________________________________________________

Please fill in the Clinical Comments in the spaces that follow.

__________________________________________________________________________________________

Clinical Data:

Indicate when lesions were first identified and if

a previous histopath report exists; include LAB name

and specimen #: indicate pertinent physical exam

(e.g. distribution of lesions) and other clinical findings.

__________________________________________________________________________________________

CBC or BM evaluations:

Include copies of actual data sheets, if

possible, otherwise summarize here.

__________________________________________________________________________________________

Chemistry Panel:

Include copies of actual lab data sheets, if

possible, otherwise summarize here

__________________________________________________________________________________________

Treatment:

Indicate treatment regimen and when started,

and if the animal is currently on treatment.

__________________________________________________________________________________________

Signature of Referring Veterinarian__________________________________ Date_______________

REMINDER!

Please be sure to include a copy of the pathology report with this form. GDC cannot register the diagnosis without a pathology report.

Patholgoy Lab Name____________________________________Phone__________Histopath report # __________ Date ___/___/___

Mail pages 1 & 2 of this form, with your check and a copy of the pathology report to:

GDC

PO Box 177

Warner, NH 03278

Revised 6/03