Shipping Frozen Semen | Pewee Valley Veterinary Center

Evaluation

Regular Evaluation Fee
Priority Evaluation (3-5 business days) Additional charge

Hospital 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
MasterCard

Credit Card #

Date

Radiograph Information - To be completed by PennHIP member

Member Number

Distractor Number

Member Name(Print)

Date of Radiograph (Month/Day/Year)

Patient Weight (lbs)

Hospital Case Number (If Applicable)

Clinical Signs

Yes
No
Not Evaluated

Severity

Mild
Moderate
Severe

Duration in months

List All Drugs Used for Restraint

The following is to be completed by the dog owner

Name

First Last

Mailing P.O. Box/Street Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone

Email

Dog Information (To ensure accuracy we recommend including a copy of the dog’s registration papers)

Registered Name

Call Name

Breed

Sex

Male
Female
Neutered
Spayed

Date of Birth

Animals listed in the PennHIP open-optional database (see last paragraph) will be designated as to whether they have permanent identification

Tattoo Number

Microchip Number

Registration Number

Sire’s Registration Number

Dam’s Registration Number

IMPORTANT: Has this dog had hip surgery?

Yes
No

If yes, procedure:

Has THIS dog had a PennHIP radiograph before?

Yes
No
Unknown

If yes, when?

OFA Rating (if known):

Age when OFA rated

I 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

Radiograph Information - To be completed by PennHIP member

The following is to be completed by the dog owner

Dog Information (To ensure accuracy we recommend including a copy of the dog’s registration papers)

Dog Information (To ensure accuracy we recommend including a copy of the dog’s registration papers)