Application for Hip/Elbow Dysplasia Database

Orthopedic Foundation for Animals
A Not-For-Profit Organization — Office Use Only: APPL _____ RAD _____ CK _____

* indicates required information

Previous application number (if any):
Other registry name:
AKC CKC

Registration number*:
Other registry number:
Sex*:
Color:

Registered name*:
Breed*:
Date of Birth (month-day-year)*:

ID Number (if any):

Tattoo Microchip

Registration number of sire*:

Date radiograph taken (month-day-year):
Show date requested*:
Registration number of dam*:

Owner name*:
Co-owner name:
Telephone:*
Mailing address*:
City / State / Zip code*:
Cell phone number (while at the show):*
List of tests requested*:
Preferred Time Requested:
Email:*

Examining Veterinarian:
Randall Popkin

Breeder’s Veterinary Services
604 Elsa Drive
Santa Rosa CA 95407

Tel: 707-495-6424
Email: bvs@sonic.net

Veterinary Information - This animal was restrained using:


 Physical Restraint
Only
Chemical
Restraint

 Tranquilizer
type:

I DID NOT

I DID verify the tattoo/microchip information on this dog

Sign here - Veterinarian Signature:

AUTHORIZATION to Release Abnormal Results* – I hereby authorize the OFA to release the results of its radiographic evaluation of the animal described on the application to the public if the results are abnormal. Registered owner, sign here:



Additional Instructions – Payments can be made by check, money order (U.S. funds drawn on a U.S. bank), cash, Visa, or Mastercard, payable to the Orthopedic Foundation for Animals. PLEASE DO NOT FILL IN CREDIT CARD INFORMATION HERE. COMPLETE THIS WHILE AT APPOINTMENT.
Visa/Master Card #

Exp. Date
Name on Card

CVV #



* I hereby certify that the radiograph submitted is of the animal described on this application and that neither the pelvic nor the elbow conformation have been surgically altered. I understand that the radiograph and/or image submitted will be retained by the OFA. I understand that the radiograph and/or image is submitted for a consensus valuation based on the independent, professional judgment of consulting board-certified veterinary radiologists, and I hereby release the OFA from any and all liability resulting from the consensus evaluation. I understand the OFA will release normal hip and/or elbow results for dogs over 24 months to the public, and by submitting this application I agree the OFA may do so. Abnormal hip and/or elbow results will not be released to the public unless the initials of a registered owner appear in the authorization box below. Normal hip results are defined as consensus evaluations of Excellent, Good, or Fair. Abnormal hip results are defined as consensus evaluations of Mild, Moderate, or Severe. For the purpose of determining whether or not the results will be released to the public, consensus hip evaluations of Borderline are considered abnormal. Normal elbow results are defined as a consensus evaluation of Normal. All other elbow consensus evaluations are considered abnormal.

Thank You