Alpharetta Animal Hospital-Shoulder Osteochondrosis

Registered name:

Breed:

Sex:

ID Number (if any)

Tattoo

Microchip

Owner name:

Co-Owner name:

Mailing address:

City:

State:

Zip/postal code:

Phone:

Email:

Registration Number:

Other registry name:

Date of Birth :

Date radiograph taken :

Registration number of sire:

Registration of number of dam:

Film no.

Examining veterinarian’s name or veterinary hospital

Mailing Address:

City:

State:

Zip/postal code:

Phone:

Email:

I hereby certify that the radiograph submitted is of the animal described on this application. I am aware that the radiographic image will be retained for the records of the Orthopedic Foundation for Animals, Inc. I understand the evaluation is based upon the independent, professional judgment of consulting radiologists, and I hereby release the OFA from any and all liability resulting from the evaluation. I understand that only normal results will be released to the public unless the initials of a registered owner appear in the authorization box below which permits the OFA to release abnormal results to the public.

Signature of owner or authorized representative