University of Pennsylvania School of Veterinary Medicine Secion of Medical Genetics
Send Samples to:
School of Veterinary Medicine
The University of Pennsylvania
Blood Transfusion Lab		 3900 Delancey Street, Room 4013
Philadelphia, PA 19104-6010
Lab Phone (215) 573-6376
Fax (215) 573-2162		 Visit our Website @:
www.vet.upenn.edu/penngen
mailto:penngen@vet.upenn.edu
Phone (215) 898-8894

Metabolic Genetic Screening Submission Form

Sample Submitted: (Mark as many as applicable)
Urine 2-5mls (required)       Serum       EDTA Whole Blood       Other:
Collection Date:       Shipping Date:

Veterinarian Information:
Name:
 Hospital Name:
Address (line 1):
 Phone:
Address (line 2):
 Fax:
City:
 Email:
State:
 Zip Code:
Country:

Owner/Agent Information: (if different from above)
Name:
 Hospital Name:
Address (line 1):
 Phone:
Address (line 2):
 Fax:
City:
 Email:
State:
 Zip Code:
Country:

Patient Information: (call name and breed required)
Patient's Official Name:
 Call Name:
 Age:
  
Species:
 Breed:
 Sex:
M F		 Neutered?:
Yes No
AKC (yes/no or specify):
 Registration Number:
 Other Comments:

Clinical Information Required for Testing
History and Clinical Signs (onset, specific signs, physical examination):
CBC and Urinalysis Results:
Medication:
Special Diet:

All information will be keep strictly confidential.

Results will be available approximately 3 weeks from receipt of sample.