OFA Hip and Elbow Dysplasia Form Application for Hip/Elbow Dysplasia DatabaseRegistered NameBread:SexPlease selectMaleFemaleId Number if anyPlease selectTattooMicrochipOwner name:Co-owner name:Mailing Address: Mailing Address: City State / Province / Region ZIP / Postal Code PhoneEmail Registration numberAKCCKCOther Registry Name:Other Registry #:Registration number of sire:Registration number of damDate of birth MM slash DD slash YYYY Film No.Date radiograph taken MM slash DD slash YYYY Examining veterinarian Name or veterinary hospital:I hereby certify that the radiograph submitted is of the animal described on this application and that neither the pelvic nor the elbow conformation have been surgically altered. I understand that the radiograph and/or image submitted will be retained by the OFA. I understand that the radiograph and/or image is submitted for a consensus evaluation based on the independent, professional judgment of consulting board-certified veterinary radiologists, and I hereby release the OFA from any and all liability resulting from the consensus evaluation. I understand the OFA will release normal hip and/or elbow results for dogs over 24 months to the public, and by submitting this application i agree the OFA may do so. Abnormal hip and/or elbow results will not be released to the public unless the initials of a registered owner appear in the authorization box below. Normal hip results are defined as consensus evaluations of excellent Good or Fair. Abnormal hip results are defined as consensus evaluations of Mild, Moderate, or Severe. For the purpose of determining whether or not the results will be released to the public, consensus hip evaluations of Borderline are considered abnormal. Normal elbow results are defined as a consensus evaluation of normal. All other elbow consensus evaluations are considered abnormal. Signature of owner or authorized representativeAuthorization to Release Abnormal Results I hereby authorize the OFA to release the results of its radiographic evaluation of the animal described on this application to the public if the results are abnormal.initials of registered ownerVeterinary informationThis animal was restrained using: Physical Restraint Only Chemical Restraint Anesthesia (type:) Tranquilizer(type:) Other (type:) I DID verify the tattoo/microchip information on this dog I DID NOT verify the tattoo/microchip information on this dog Anesthesia (type:)Tranquilizer(type:)Other (type:)Only dogs with Verified Permanent Identification (VP!) will have their results transmitted to the AKC for inclusion in their registration and pedigree documents.FeesAnimals Over 24 Months Hip dysplasia database only ................................................ $35.00 Hips plus elbows (together)................................................ $40.00 Elbow dysplasia database only.............................................. $35.0 Litter of 3 or more submitted together...................................... $90.00Animals Under 24 Months Preliminary hip evaluation .................................................. $30.00 Preliminary elbow evaluation ............................................... $30.00 Preliminary trips plus elbows (together) ..................................... $35.00 Litter of 3 or more submitted together...................................... $60.00 Kennel rate—lndividuals submitted as a group. owned/co-owned by same person. Minimum of 5 individuals ............................................ $15 per study Consultation Other radiographic: studies .................................................$30.00 Payments can be made by check, money order (0.5. funds drawn on a U.S. bank), cash, Visa, or Master card, payable to the Orthopedic Foundation for Animals.
