Disease Group:   CANINE HYPOTHYROID

Status (please circle):       unaffected……..hypothyroid
 

Kennel Club No/Name.…………………………………………………….…………………   

Family History (any close relatives affected?)………………………………………………….

Other diseases …………………………………………………………………….

Relationship to other dogs we have sampled, if known:………………………………….

Hypothyroid   Age of onset  ……y ……m

Recent therapy (if any)  ………………..…………………………………….……….....…………

Therapy for endocrine disease (if any)  ………………………………………….…..…………

Response to endocrine therapy                     Yes                        No

Results:         T4:…………… FreeT4:…………….. T3AA:…………….. T4AA:……………..

                       TSH:………………Anti-thyroglobulin antibodies:………………...

Informed consent

I have read and understood the accompanying information leaflet explaining the UK DNA Archive for Companion Animals.

I appreciate that in order to advance our understanding of veterinary diseases there is a need to determine how a particular condition relates to the genetic profile of the animal.                                                                    

I understand that any genetic tests relating to my animal will not provide specific information about its condition but will contribute to the general body of knowledge about the disease in the species. I realise that no specific information regarding genetic tests on my animal will be reported back to me.

I agree to DNA being extracted from blood that may be taken from my animal for the agreed clinical investigations and that is surplus to requirements for clinical tests. I agree that this will be used entirely for research purposes. I give consent for the material to be stored and made available to bona fide scientists in the field of animal disease and genetics.

I understand that all information I give will be held in strict confidence and the source of the archived DNA will not be divulged to any third party unconnected with the research project (e.g. insurance companies)

I understand that this research will not benefit my animal directly, but in the future may be of benefit to other animals.

I understand that the custodianship of the DNA resides with the University of Liverpool but I retain the right to remove my animal’s sample from the archive in the future if so wished.

          Signed…………………………………………………      Date……………………….

          Species…,dog/cat/horse/……… Breed……………………………………

          Animal Name………………………………………………