Animal Tissue Form

For Viewing Purposes Only - Licence applicants must use the available WORD or PDF versions of this form when submitting it to the Natural Health Products Directorate (NHPD).

Protected when completed

1. - Ingredient derived from animal tissue:

• Name:

2. - Used as

• Ingredient OR
• in processing of product

3. - Animal species

• cattle
• pig
• deer or elk
• poultry
• sheep
• crustacean
• goat
• Other:

4. - Animal tissues used

• adipose tissue/omentum
• antler velvet
• appendix
• bile
• blood/blood products
• bones (other than vertebral column)
• brain
• colostrum
• dorsal root ganglia
• dura mater
• enzymes
• eyes/corneas
• heart/pericardium
• intestine
  • small
  • large
• kidney
• lung
• mammary gland
• milk and milk products
• muscle, skeletal
• ovary
• pancreas
• pituitary
• saliva, salivary gland
• skin/hides
• skull
• spinal cord
• spleen
• tendons, ligaments
• testis
• thymus
• thyroid
• tonsils
• trigeminal ganglia
• vertebral column
• Other:

If you checked cattle; deer or elk; sheep; or goat, in section 3 please fill in the following two sections. (5. & 6.)

5. - What is (or will be) the age of the animals used?

Under:
or Range from:
to:

6. - Country/Countries from which the animals originated (or will originate)?

• Argentina
• Australia
• Brazil
• New Zealand
• United States
• Uruguay
• Other:

Signing Authority

I am aware that the above information may be used to conduct a risk-based assessment before any decision is taken with regard to the accompanying Product License application. I agree that if the company changes either the source or the type of animal sourced material used in the product prior to or after receiving final approval for a product submission, it must submit an Amendment of Product License form to the Natural Health Products Directorate of Health Canada.

• Signature:
• Date (yyyy-mm-dd):