Fort Collins General Submission Form

csu.cvmbs.colostate.edu

Fort Collins General Submission Form

www.dlab.colostate.eduPhone: 970-297-1281Fax: 970-297-0320GeneralSampleSubmissionFormOFFICE USE ONLYOpened By:DHL USPS FX Courier OtherFrozen Dry Ice Ice Pack RT Other FixedSample Type(s):Comments:VTH USE ONLY (Patient Card Here)FedEx/UPS/Drop Off Address:CSU Veterinary Diagnostic Laboratory300 West Drake RoadFort Collins, CO 80526Veterinarian:Clinic:Address:USPS Only Address: CSU Veterinary Diagnostic Laboratory200 West Lake Street1644 Campus DeliveryFort Collins, CO 80523-1644Clinician/Resident: _______________________________________________Pager: ___________________________ H-Account/Fund: __________________Owner/Producer:Business/Premise ID:Address:City:Phone:State: Zip:Person to be Billed: Veterinarian Owner/Producer Report Results To: VeterinarianOwner/ProducerCity:Phone:State:Zip:Send Results By:Fax:Email:Phone:Avian (specify):EquineWildlife/Exotic (specify):Feline Ovine PorcineBovine Camelid CanineCaprineOther (specify):Reptile/Amphibian (specify):Specimen(s)Whole BloodSerum Culture Plate Isolate Swab (specify):Milk UrineFecesSemenFetusWhole BodyTissue(s) (specify):Environmental (specify):Other (specify):Additives/Media Used:ANIMAL IDENTIFICATION (if >3 samples, continue on Multiple Animal Submission Form)Animal Name/ Number/ ID Breed AgeSex Collection DateHISTORY (include clinical signs, differential diagnoses, antibiotic use, vaccine history, duration, number of animals affected, etc.) If more space isneeded, please continue on and attach an additional page.STAT -- Additional Charge, Contact Lab for PricingResults Phoned/Faxed/Emailed Date ________________ Initials _______Last Updated 11/29/2012 cbw


Vet:Animal ID:OFFICE USE ONLYSeparate submission forms are required for ClinicalPathology, Clinical Immunology and Necropsy.PANELS/SCREENS -- See User Guide for tests includedAbortion Serology PanelAbortion ScreenConjunctivitis PanelDiarrhea ScreenRespiratory ScreenRespiratory Serology PanelAVIAN DIAGNOSTICS (if more than one test type is listed, please circle desired test)APMV-1 (NDV) (PCR / VI / HI / ELISA)M. gallisepticum (plate test / ELISA)Psittacosis (Chlamydophila) PCRSalmonella Enteritidis PCRInfluenza (PCR / VI / HI / AGID / ELISA)M. synoviae plate testSalmonella - environmentalPullorum/Typhoid plate testInfectious Bronchitis Virus (IBV) ELISAM. gallisepticum/M. synoviae PCRSalmonella - mortalityWNV PCRBACTERIOLOGY (if more than one test type is listed, please circle desired test)Clostridial Fecal CultureMycobacterium CultureAerobic Culture ofBacillus anthracis PCRC. perfringens Genotyping PCRMycoplasma** (Culture / PCR)Anaerobic Culture** ofBrucella spp. PCRFrancisella tularensis PCRQ Fever (C. burnetii) (PCR / ELISABlood Culture**Campylobacter CultureFungal CultureStreptococcus equi PCRUrine CultureCEM** CultureLeptospirosis PCRYersinia pestis (plague) PCRAntibiotic SusceptibilityClostridium perfringens Enterotoxin Milk submissions - *Use 'Milk Sample Submission Form'*SerologyBovine Camelid Canine Equine Feline Ovine/CaprineGeneralBrucella abortusIgG Estimate ANABrucellaANABrucella (caprine)Cryptococcus SerologyIgG EstimateIgG QuantBrucella canisIgG QuantIgA QuantJohne's AGIDFungal Serology PanelIgG QuantLepto-5 MAT IgA QuantIgG SNAPIgG Quant(Aspergillus/Histoplasma/Johne's ELISAIgG QuantIgM QuantPorcineBlastomyces/Coccidioides)Lepto-5 MATIgM QuantLepto-5 MATBrucella abortusImmunofixationLepto-5 MATProtein Electrophoresis** Special Media Required; Please Contact LaboratoryOther (please specify test & species):VIROLOGY/VIROLOGY SEROLOGY (if more than one test type is listed, please circle desired test)GeneralCanineFelineEquineBTV PCRCanine adenovirus-1 (ICH) & 2 PCRFHV SNEHV-1 (SN / FA)EHD PCRCCV FAFHV/Chlamydophila Duplex PCREHV-3 (SN / PCR)Rabies FACDV (SN / FA / PCR)FCV (SN / PCR)EHV-4 SNRotavirus ELISACDV IgG/IgM IFAFPV (HI / FA / PCR / SNAP ELISA) EHV 1 & 4 PCRCPV-1 (Minute virus) PCRFIP (FA / IFA / PCR)EVA (SN / PCR / VI)BovineCPV-2 (HI / FA / PCR / SNAP ELISA)FIV/FeLV SNAP ELISAEIA (AGID / ELISA) *Special Form Required*BHV-1 (IBR) (SN / FA / PCR / VI) CHV (Herpesvirus) (SN / FA / PCR)FIV PCRInfluenza (HI / PCR)BHV-4 PCRInfluenza (HI / PCR)VSV - IND/NJ (SN / CF)BHV-5 PCROvine/CaprineWEE PCRBVD I & II (SN / PCR)BTV (AGID / PCR)WNV (IgM ELISA / PCR)BVD (FA / VI / ELISA)PorcineBVD (SN / FA / VI)BRSV (SN / FA / PCR / VI)CSFV PCRCAE (AGID / PCR)CamelidPI3 (SN / FA / VI)Influenza (HI / PCR)Caprine Herpesvirus PCRBVD I & II (SN / PCR)BCV FAPRRS PCRChlamydophila PCRBVD (SN / FA / VI)BLV (AGID / PCR)PRV ELISAEnzootic Nasal Tumor Virus PCRBTV (AGID / PCR)Chlamydophila PCRVSV - IND/NJ (SN / CF)TGE (SN / FA)Jaagsiekte Sheep Retrovirus PCROPP (AGID / PCR)OHV-2 (MCF) PCRPARASITOLOGY & PARASITOLOGY COMBINATIONS (if more than one test type is listed, please circle desired testGeneralBaermann (Qualitative / Quantitative)Fecal FlotationFecal Screen - Includes float, direct, IFAParasite Identification (Internal / External)Occult BloodSoil AnalysisTrichinella DigestToxoplasma gondii MAT - non canine/felineCryptosporidium PCRGiardia PCRCryptosporidium/Giardia IFARuminant/CamelidSedimentation (flukes)Cryptosporidium acid fast (bovine only)Toxoplasma gondii PCRNeospora cELISAT. foetus (Culture - InPouch / PCR)Owner:Species:Canine/FelineHeartworm serologyMicrofilaria (Knott's Test)Giardia ELISAOther (please specify test & species):EquinePinworm (Cellophane Tape Technique)Piroplasmosis cELISA (T. equi & B. caballi)T. foetus/Trichomonads (Culture - Diamonds / Culture - InPouch / PCR)Ehrlichia/Lyme/Anaplasma/Heartworm ScreenEhrlichia canis IFA (titer)with Ehrlichia/Anaplasma/Neorickettsia PCREhrlichia/Anaplasma/Neorickettsia PCRBartonella spp. (PCR / ELISA - feline only)Bartonella spp. PCR plus ELISAHaemoplasma spp PCRFeline Fever Panel - Hemoplasma/Ehrlichia/Bartonella PCR with Toxo ELISA and Bartonella ELISAFeline Blood Donor Panel - Hemoplasma/Ehrlichia/Bartonella PCRCanine Fever/Blood Donor Panel - Ehrlichia/Bartonella/Haemoplasma/Rickettsia PCRToxoplasma gondii (IgG-IgM ELISA / PCR)Neospora caninum (IFA / PCR)RMSF IFA (titer)IFA with Rickettsia spp. PCRRickettsia spp. PCROther (please specify test & species):ENDOCRINOLOGYFelineEquineCanineTotal T4Dexamethasone Suppression (low or high dose)Total T4Insulin ConcentrationACTH Stimulation (pre/post)Dexamethasone Suppression (low or high dose)Insulin ConcentrationThyroid Panel (T4, eTSH, TGAA ELISA)Endogenous ACTHEndogenous ACTHBasal CortisolInsulin ConcentrationPhenobarbital ConcentrationTotal T4ACTH Stimulation (pre/post)Basal CortisolCHEMISTRY/TOXICOLOGYCopper w/HistoSeleniumBromideLeadOther:Ironw/HistoVitamin ACalculiArsenicZincw/HistoVitamin ENitrateMercuryPATHOLOGYNecropsy (separate form required)HistopathologyPathologist Requested2nd Opinion HistopathologyLiver Panel (Histo, Copper Quant & Special Stains)Histopath Mailers NeededMast Cell Tumor ProfileClinical Dermatology Consultation (Additional Fee)Endometrial BiopsyIHC for

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