2026 Health Clinic Signup Form

2026 Health Clinic Sign Up - FREE Clinic

Disclaimer - if, due to human error or shipping complications, any test cannot be run; neither ISCA nor ISCAF is responsible for the resubmission of any sample
ITEMS NEEDED (REQUIRED IN SOME CASES) TO COMPLETE

THE HEALTH CLINIC SIGN UP FORMS

These items may require some digging before you are ready to begin
Of course the usual suspects:

Name

Address

Phone

Email

Dog Information:

Registration #

Registered name (NO titles)

Permanent ID (Microchip or Tattoo) if you are doing Eye Exam

Sire’s Registered Name (NO titles)

Sire’s Registration Number

Dam’s Registered Name (NO titles)

Dam’s Registration Number

Veterinarian Information:

Name

Address

Phone

Email

CHIC DNA Test:

You need to know what illnesses or diseases your dog has had

Thyroid Tests:
We do take puppies now!

Thyroid Medications if on one (dosage and how often given)

Other Medications if on one (dosage and how often given)

Eye Exam:

     You need to register your dog at OFA BEFORE continuing with this form.

     See the ISCA website (Health Page) for those instructions

     Permanent ID (Microchip or Tattoo) required for Eye Exam

          If you do not have one, you can purchase one through the Paid Form for $10

Here is the link to the Health Page for OFA instructions (scroll down to Eye Clinc).

https://irishsetterclub.org/health/health-clinic/
PLEASE BE AWARE - Results on these tests could take up to 30 days to be received. And even longer for OFA to post the results.
YesNo

2026 ISCA Foundation

Jane Gavin Health Clinic

Wendy & Matt Czarnecki Thyroid Clinic

Information Form

For the Free Clinic
YOUR COMPLETED FORMS WILL BE WAITING FOR YOU AT THE NATIONAL.

The Free Clinic covers CHIC DNA, Thyroid and Eye Test. If you want any other tests run for your dog - complete this form, then go back in on the PAID form for the rest of the tests. DO NOT fill in CHIC DNA or Thyroid on the PAID form unless you no longer want to be part of the Free Clinic.

To be part of the Free Clinic (all tests)

you must agree to have your results sent to OFA and

agree to publish ALL results (positive or negative).

You can do thyroid on a puppy - however you need to recognize that OFA will not list the results on their website nor give a certification. But we can do the test if you'd like!

You may print (using your browser's print option) copies of the worksheets you are making now for your own reference. Print each page as you go - before you move to the next page (or chose your next test). You will not have the opportunity to print once you move on. The information you are providing will be loaded into the official forms to be used at the clinic. Type carefully. Double check your work by using the Back Option (at the bottom of each page) if needed. Your work will be saved in your browser as you go along. Once you hit submit you will not be able to make changes. Required fields are marked with a Red *
Owner's Name:*
Co-Owner's Name:
Address:*
City:*
State:*
Zip Code:*
Province:
Country:
Phone:*
E-Mail - type carefully (you will receive a receipt at this e-mail address that your forms were received):*
Dog's Registered Name - NO titles please:*
Call Name:*
Date of Birth*

MMDDYYYY
Age (as of the test date) REMEMBER OFA will not recognize the test on puppies!:*
Registration Number:*
AKC or CKC?*
Sex:*
ID Number:
REQUIRED if you are doing Eye Clinic
Microchip or Tattoo?
Weight:*
Sire's Registration Number:*
Sire's Registered Name - NO titles please:
Dam's Registration Number:*
Dam's Registered Name - NO titles please:
Veterinarian's Name:*
Address:*
City:*
State:*
Zip Code:*
Phone:*
Veterinarian's E-mail:

Microchipping And Eye Exam
YesNo
Permanent ID (Microchip or Tattoo) is required for our Free Eye Exam! You did not fill in a Microchip number - therefore you cannot proceed to the Eye Clinic. Please use the back button and fill in the Microchip number.

If you do not have a Microchip for your dog, you can purchase one via the Paid Clinic. Close out of this form and go to the Paid clinic to purchase a Microchip. Or you can choose No above and not receive the eye exam.

Once you have purchased a Microchip, you will receive an email from the Paid Form that will have a code under your Dog's Registration Number. Use that code in the mircorchip number on this form to show you purchased a Microchip.

Our price is lower than you can get at your vet! We would put the chip in on Wednesday when the blood is drawn for all other tests.
To be part of the Free Eye Exam, you will need to register for the clinic, through OFA BEFORE filling out the rest of this form. If you have not done so, exit and see the instructions on the ISCA Webpage (Health Page). The Eye Clinic will be held on Thursday May 28th. Appointments are from 10:30am to 2:45pm.

PLEASE NOTE - having your dog's record at OFA is NOT what is meant here. You need to have signed your dog up for THIS CLINIC at OFA before proceeding.

ISCA Health Information

When you complete this Health Clinic signup form; you will automatically be taken to the Appointment page. Please choose an appointment time that works for you. All dogs are required to have an appointment. NO WALK-INS WILL BE ACCEPTED.

When deciding the time for your appointment, if you have a dog showing that day, the vet says dogs are NOT bothered by the drops like people are. Their eyes will be back to normal in 2-3 hours.

If an appointment time needs to be changed at a later date, we will try to help you. We cannot guarantee a time will be available later. No appointments can be changed after April 16th.
YesNo
You have indicated you are not willing to make the results public.

You will now be taken to the rest of the Health Clinic form and your dog will not be receiving the Free Exam. We are not offering a paid Exam.
YesNo
You said you have not preregistered with OFA. If you have, please change your response above.

If you have not preregistered AND would like to have your dogs eyes examined, close out this form and follow the instructions made available on the ISCA Website (Health Info Page) for signing up at OFA in advance.

Proceeding with the Health Clinic sign up now means your dog
will NOT be getting a Free Eye Exam!!!!!
Enter the Case # provided by OFA in the email they sent you. It is also listed in the lower left corner on the PDF they sent you (below the bar code):*
If you cannot find this code, see instructions on ISCA website

Health Clinic - CHIC DNA Repository
DNA Sample Submission Agreement:

I hereby donate, assign, and transfer a DNA sample of the dog named above to the CHIC DNA Repository for research purposes and warrant my authority to do so. I understand that any future use or distribution of this DNA sample will be within the sole direction and authority of the CHIC DNA Repository. I authorize the OFA and the AKC CHF to provide any researchers receiving a portion of this sample with all necessary information including pedigree and health history to make the sample useful. My intent in providing this DNA sample is to further research into canine health issues. I hereby relinquish all rights to, and ownership of, the DNA sample.
Type your full name below to signify your agreement:*

Health Clinic - Thyroid Test
Brief History:*
On Medication - OTHER than Thyroid?*
If yes, brief list:
Dosage?
How many hours before blood drawn?
On any supplements?*
If yes, brief list:
On Thyroid Medication?*
If yes, brief list:
If yes, when?
Dosage?
How many hours before blood drawn?
How long was the dog on the treatment:
How was it established the animal needed to go on replacement therapy and how was it determined they could stop?
Please provide the most recent vaccination history:
What was the date of the dog's last physical exam?
What was the date of the last successful breeding?
Please list and other medical issues or information you feel is pertinent

Health Clinic - Thyroid Information for CHIC
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 the registered owner appear in the authorization box below which permits the OFA to release abnormal results to the public. Type your full name below to signify your agreement:*
TO BE PART OF THE FREE CLINIC - YOU MUST AGREE TO RELEASE POSITIVE AND NEGATIVE RESULTS.

IF YOU DO NOT WISH TO DO SO - CLOSE OUT OF THE FORM

You may still do a Thyroid test on the Paid Form.
AUTHORIZATION TO RELEASE ABNORMAL RESULTS I hereby authorize OFA to release the results of its evaluation of the animal described on this application to the public if the results are abnormal. Type your full name below to signify your agreement:*

Thank you for signing up!

BE SURE TO HIT SUBMIT BELOW!!!
Should be Empty: