Shipping Frozen SemenEvaluation Regular Evaluation Fee Priority Evaluation (3-5 business days) Additional chargeHospital Fax - Required for Priority Evaluation only. Please Enter Fax #Select Payment (check or credit card payment must be from the hospital): Bill Practice Check Enclosed Payable to: U of PA – PennHIP VISA MasterCardCredit Card #Date Radiograph Information - To be completed by PennHIP memberMember NumberDistractor NumberMember Name(Print)Date of Radiograph (Month/Day/Year)Patient Weight (lbs)Hospital Case Number (If Applicable)Clinical Signs Yes No Not EvaluatedSeverity Mild Moderate SevereDuration in monthsList All Drugs Used for RestraintThe following is to be completed by the dog ownerName First Last Mailing P.O. Box/Street Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country TelephoneEmail Dog Information (To ensure accuracy we recommend including a copy of the dog’s registration papers)Registered NameCall NameBreedSex Male Female Neutered SpayedDate of Birth Animals listed in the PennHIP open-optional database (see last paragraph) will be designated as to whether they have permanent identificationTattoo NumberMicrochip NumberRegistration NumberSire’s Registration NumberDam’s Registration NumberIMPORTANT: Has this dog had hip surgery? Yes NoIf yes, procedure:Has THIS dog had a PennHIP radiograph before? Yes No UnknownIf yes, when?OFA Rating (if known): Excellent Good Fair Borderline Mild Moderate SevereAge when OFA ratedI understand that this information will be entered into a medical database and the results will be employed in an ongoing scientific investigation on canine hip dysplasia. However, I am also aware that my dog’s individual statistics will be kept confidential unless I authorize their release (see below). I certify that the radiographs are of the animal described above. I am aware that the radiographs will be retained by PennHIP and not returned to me. I understand that if there are fewer than twenty dogs of my breed in the database that my dog’s ranking will be made relative to the general dog population.Authorization to Release My Dog’s Hip Scores: PennHIP is establishing an open-optional database to facilitate identifying and listing suitable breeding candidates. If PennHIP scoring indicates my dog to be appropriate for breeding (top 40% of the breed without degenerative joint disease), I authorize PennHIP to include my dog’s hip information in the PennHIP open-optional database, which will be made available to the public