Gender
Male Female

Is a pedigree available?
Yes No

Date of last vaccinations and vaccinations administered

Administering vet/person and contact information

Illness/reactions believed to be vaccine associated

Known chronic problems

Daily medications

Food/diet

Please indicate study association (check all that apply)
Pug is suspected of having PDE
Pug is related to a PDE affected pug
Affected pug had histopathology reflecting PDE
Affected pug had no histopathology
Affected pug had clinical laboratory analyses

I hereby state this information is true and correct, and grant permission to the Texas A&M Canine Research Lab
to extract DNA from the buccal samples taken from this dog for ongoing genetic studies
Yes No

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