PLEASE NOTE: RESULTS MAY TAKE LONGER THAN NORMAL DUE TO THE
LARGE QUANTITY OF TESTS THAT ARE BEING SUBMITTED TOGETHER.
Owner’s Name:________________________________________________________________________________
Co-Owner’s Name: ____________________________________________________________________________
Co-Owner’s Name:_____________________________________________________________________________
Street:_______________________________________________________________________________________
City: _____________________________________ State: _____________ Zip: ___________________
Home Phone#: ____________________________________ Cell Phone: _________________________________ 
Fax#:__________________________________
E-Mail: ____________________________________________
Breed: ___________________Date of Birth: ______ / ______ / ___________(mm/dd/yyyy)
Dog's full registered name: _______________________________________________________________________
Call Name: ____________________________
Registration #: ___________________________________
______ American Kennel Club ______ Canadian Kennel Club OTHER: _______________________________
AKC DNA #:__________________________ Microchip:______________________ Tattoo: _________________
Sex: ______ Male ______ Female Neutered/Spayed: Yes No
Coat Color: ______ Fawn ______ Apricot ______ Fawn Brindle ______ Apricot Brindle ______ Other
Sire Name: ___________________________________________________________________________________
Sire's AKC: ____________________________________________________
Dam’s Name: _________________________________________________________________________________
Dam's AKC: ____________________________________________________
*Clinic price is $25. (Kim Fish is providing S&H) -
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Cystinuria page 2 of 2
Dog's full registered name: ______________________________________________________________________
Owner’s Name: _______________________________________________________________________________
Date of urine collection: ______ / ______/___________ (mm/dd/yyyy)
Urine sample was collected how many hours after dog’s last meal? ______ hours
Dog's diet: ____________________________________________________________________________________
Has your dog had a previous cystinuria urine test? ______Yes ______ No
Results:___________ UPenn Cystinuria # (if known): ________________________________________________
Any previous health problems including urinary tract infections? ______ Yes ______ No
Current Medications (Please list all):________________________________________________________________
______________________________________________________________________________________________
Reason's for testing: (check all appropriate items)
____ MCOA Health Award ____ urinary tract infections
____ General screening ____ difficulty urinating
____ Showing ____ blood in urine
____ Breeding ____ crystals in urine
____ Suspicious clinical signs ____ calculi (stones)
____ Relative known to be affected Relationship: ____________________________________________
______ Number of submission forms ______ Number of urine samples
2011 Northeast Ohio Mastiff Picnic
“Cystinuria Clinic”
Cystinuria Clinic Fee: *$25 per sample (special clinic price)
CASH OR CHECK ONLY! Make checks payable to "Kim Fish"
If you have an affected dog, please inform UPenn directly and send them information on the diagnosis of Cystinuria (e.g., stone analysis). All information will be kept strictly confidential.
Cystinuria testing is free to Mastiffs that have previously tested positive and have submitted blood to UPENN Research.
PLEASE NOTE: UPenn needs blood, urine, 5 generation pedigree, DNA Consent Form and Questionnaire from all Mastiffs that test positive as well as from their close relatives (vertical & horizontal). UPenn’s Cystinuria research is dependent on DNA (blood) and accurate data. Please participate in Cystinuria Research!
