Application for Dentition Database
Adult teeth must be fully erupted for evaluation
I hereby certify that the information submitted is of the animal described on this application. 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 _________________________________________________________________
Individual dog ....................................................................................$15.00 each
A litter of 3 or more submitted together ..................................$30.00 total
o Full dentition with all adult (permanent) teeth fully erupted
o Persistent (retained) deciduous teeth noted with a “P” on the
dental chart
o Missing teeth noted with an “M” on the dental chart
o Other (please specify) ________________________________
________________________________________________
Veterinarian Dentition Examination Results
Orthopedic Foundation for Animals
2300 E Nifong Blvd, Columbia, MO 65201-3806
Phone: (573) 442-0418; Fax: (573)875-5073
www.offa.org
A Not-For-Profit Organization
APPL _______
RAD ________
CK _________
Oce Use Only
Oce
Use
Only
Authorization to Release Abnormal Results, “Open” Database
I hereby authorize the OFA to release all veterinary exam results indicated below on this application to the public.____________ (initials of registered owner).
Kennel rate:
Individuals submitted as a group, owned/co-owned by the same person
Minimum of 5 individuals ........................................................................ $7.50 each
No charge for dogs without full dentition that are placed in the “open” database
Fees
q I certify that I have completed the dental exam and marked o the appropriate exam results.
q I DID verify tattoo/microchip on this dog q I DID NOT verify tattoo/microchip on this dog
_______________________________________________________________________________________________________
Veterinarian Signature Specialty: q Practitioner, q Specialist Date
07/21/14
R
G G
L
Maxilla
Mandible
110 109 108 107 106 105 104 103 102 101 201 202 203 204 205 206 207 208 209 210
411 410 409 408 407 406 405 404 403 402 401 301 302 303 304 305 306 307 308 309 310 311
Registered name: AKC Registration Number: Other registry name:
Other registry #:
Breed: Sex: Date of Birth (MM/DD/YY): Date of exam (MM/DD/YY):
ID Number (if any): q Tattoo q Microchip
Registration number of sire: Registration number of dam:
Owner name:
ä VETERINARIAN INFORMATION ä
Examining veterinarian’s name or veterinary hospital:
Co-Owner name: Mailing Address:
Mailing address: City: State: Zip/postal code:
City: State: Zip/postal code: Phone: FAX #:
Phone: Veterinarian Email:
Owner e-mail. Please print one letter/symbol per cell.
Card Number
Payments can be made by check, money order (U.S. funds drawn on a U.S. bank), cash, Visa, or Mastercard, payable to the Orthopedic Foundation for Animals.
Card Type: q Visa q MasterCard
Exp. (MM|YY) CVV
________________________________________________________
Cardholder Name
