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OHSU Transgenic Mouse Models Shared ResourceORDER FORM PROJECT INFORMATION: FORMCHECKBOX Mouse Embryo Cryopreservation FORMCHECKBOX Mouse Embryo Reconstitution FORMCHECKBOX Mouse Sperm Cryopreservation FORMCHECKBOX IVF FORMCHECKBOX Speed Cryo for Embryo FORMCHECKBOX ICSI FORMCHECKBOX Mouse Strain Rederivation FORMCHECKBOX other Storage of Frozen Embryos / Sperm: *: $100/year/line for storage at TMM FORMCHECKBOX – with OHSU TMM* FORMCHECKBOX – Other CONTACT PERSON: Name: FORMTEXT ????? Phone: FORMTEXT ????? Email: FORMTEXT ????? SPERM INFORMATION(For IVF, ICSI): Sperm Genotype (1): Homo FORMCHECKBOX Het FORMCHECKBOX Number: FORMCHECKBOX Tube(s) or FORMCHECKBOX Straw(s) Genetic Background: FORMTEXT ????? Sperm Genotype (2): Homo FORMCHECKBOX Het FORMCHECKBOX Number: FORMCHECKBOX Tube(s) or FORMCHECKBOX Straw(s) Genetic Background: FORMTEXT ????? EMBRYO INFORMATION(For Mouse Embryo Reconstitution): Embryo Genotype (1): Homo FORMCHECKBOX Het FORMCHECKBOX Number: FORMCHECKBOX Tube(s) or FORMCHECKBOX Straw(s) Genetic Background: FORMTEXT ????? Embryo Genotype (2): Homo FORMCHECKBOX Het FORMCHECKBOX Number: FORMCHECKBOX Tube(s) or FORMCHECKBOX Straw(s) Genetic Background: FORMTEXT ????? MOUSE STRAIN INFORMATION:Mouse line Genotype (1): Homo FORMCHECKBOX Het FORMCHECKBOX Genetic Background: FORMTEXT ?????Mouse line Genotype (2): Homo FORMCHECKBOX Het FORMCHECKBOX Genetic Background: FORMTEXT ?????Health Status (SPF, etc): FORMTEXT ?????INVESTIGATOR DATA: IACUC Animal Protocol Number: FORMTEXT ????? Name: FORMTEXT ????? Email: FORMTEXT ????? Phone: FORMTEXT ????? OHSU Mail Code: FORMTEXT ????? Department: FORMTEXT ????? Fax: FORMTEXT ????? Institution (if not OHSU): FORMTEXT ????? BILLING INFORMATION: Alias/Account: FORMTEXT ????? Billing Contact Person: FORMTEXT ????? Email: FORMTEXT ????? Phone: FORMTEXT ?????OTHER INFORMATION:Additional Information / Special Requirements: FORMTEXT ?????* If you have questions, please call the director, Lev Fedorov 503 494 2822 or send an e-mail to: fedorovl@ohsu.edu ................
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