Alpharetta Animal Hospital- Thyroid form

Step 1 of 3

33%

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:

Other registry #:

Date of Birth :

Date radiograph taken :

Registration number of sire:

Registration of number of dam:

Date of last routine vaccination:

Examining veterinarian’s name or veterinary hospital

Mailing Address:

City:

State:

Zip/postal code:

Phone:

Email:

I hereby certify that the sample submitted is of the animal described on this application and that this animal has not received thyroid medication of any type for 3 months prior to this test. 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