Department of Clinical Sciences
1060 William Moore Drive
Raleigh. North Carolina 27606
919.513.6230 (Administrative Office)
919.513.6336 (Fax)
NC State University - Ocular Genetics Consent Form
Sampling
We would like to collect a blood sample from your dog for current and future research. Our research
goals are to improve ocular health and develop tests for inherited eye diseases in dogs. By signing this
consent, you agree that the sample and information from medical records may be used by NCSU and
its collaborating partners for research on the genetic causes of inherited diseases. We may also need to
contact you in the future for additional information regarding your dog. AKC registration information is
being collected because for certain studies it is important that dogs not be too closely related.
*All information about you and your dog will be treated confidentially
Patient Information
AKC Registration No.:
Breed and color:
Registered name:
Dog’s name:
Date of birth:
Sex (M, F, MC, FS)
Additional health information (diseases etc.)
Owner i nf o rm at i on (Or patient label)
First name:
Last name:
Street Address:
City, State
e-mail:
Phone number:
Attachments
Copy of Pedigree info
Copy of Medical record
Zip Code:
Yes
No
Yes
No
Owner Signature:
Please contact Dr. Keith Montgomery or Dr. Kate Meurs with any questions:
montgokw@gmail.com or via phone: 919-513-6213
2
Sample collection
Please ask your veterinarian or a veterinary technician to pull a blood sample into an
veterinary hospitals have these readily available.
EDTA tube. Most
1. Blood drawn into a Standard EDTA Tube does not need to be refrigerated.
2. Blood draw volume should be 2 to 3 ml, if possible.
3. Please label tube well, with dog’s call name and family last name and send the samples
to our lab via the address below.
Blood drawn does not need to be mailed back with ice packs or be shipped overnight.
However, if possible please try to send the sample within a few days by standard mail.
Please refrigerate samples until the blood can be mailed (i.e., if the blood was drawn late
Saturday and cannot be mailed until Monday, it’s a good idea to refrigerate it between
Saturday and Monday).
Questions? Contact Info: montgokw@gmail.com
Please return the form with your sample and mail to:
NCSU - College of Veterinary Medicine
ATTN: Veterinary Genetics Laboratory
Dr. Keith Montgomery (Ocular Genetics)
Research Bldg. 228
1060 William Moore Dr.
Raleigh, NC 27607
Thank you very much for your submitting a sample, we greatly appreciate
it!