Please provide the following contact information: (*required) THIS IS NOT AN ONLINE SUBMISSION FORM. This form must be printed and submitted by mail or FAX Use this form for requests to RENT equipment (service plans B & C) as well as to request Holter readings if you own equipment (service plan A)
*First Name *Last Name Street Address Address-Continued City State/Province Zip/Postal Code Country Work Phone *Home Phone FAX E-mail Alternative E-mail
Animal Information
Service Plan B: Pre-Breeding Screen ($100 Deposit required at time of order to be deducted from balance due; $135 for 1st dog and $95 for each additional dog; WSU supplies equipment).
Service Plan C: Diagnostic Screen ($100 Deposit required at time of order to be deducted from balance due; $220 for each dog; WSU supplies equipment).
Payment CHECK (Checks should be made out to payable to VCGL-WSU)
VISA MASTERCARD (Note: These are the only credit card types accepted)
Card Number Expiration Date VCODE** Signature
**The last three digits of the long number on the back of the credit card, generally located close to the signature line. NOTE: In order to process a credit card, the following information is required: Name of card owner (as it appears on the credit card), mailing address of card owner, card number, card expiration date and card’s VCode (3 digits on back of card).
EMAIL IS NOT SECURE. DO NOT EMAIL CREDIT CARD INFORMATION.
You may either print this form & hand-write the information OR complete this form on your computer & then PRINT the completed form. (This is NOT an online submittal form).
Please send the completed form, completed tapes & check payment payable to VCGL-WSU to:
Dr. KM Meurs Veterinary Cardiac Genetics Laboratory Washington State University Post Office Box 605 Pullman, WA 99163
If you have questions or to request equipment, please call Dr Meurs or Esther Wilson at 509-335-6038 during regular office hours or EMAIL holters@vetmed.wsu.edu
Veterinary Cardiac Genetics Laboratory Washington State University Post Office Box 605 Pullman, WA 99163 Phone: 509.335.6038 FAX: 509.335.6038 EMAIL: holters@vetmed.wsu.edu
