FACULTY OF SCIENCE School of Animal and Veterinary Sciences Veterinary Diagnostic Laboratory SAMPLE SUBMISSION FORM Locked Bag 588, Boorooma Street Phone: +61 2 6933 4000 Wagga Wagga NSW 2678 Australia Fax: +61 2 6933 4348 ABN: 83 878 708 551 Email: [email protected] ABN: 83 878 708 551 Veterinarian/Agent: Animal ID: Address: Species: Email: Invoice (tick ): Age: Breed: Ph: Owner’s name: Fax: Owner’s address: □ submitter □ CSU code __________________ Gender: PIC: HISTORY, SIGNS, LESIONS: DIFFERENTIAL DIAGNOSIS: 1. NUMBER of SAMPLES 2. n 3. Blood, clotted Blood, EDTA Blood, hep Swab Faeces Blood, citrate Blood, fl/ox Slide Fluid Other TESTS REQUESTED (tick ) Biochemistry Profiles Canine & feline panel Feline health Equine panel Canine health Production animal panel Greyhound racing Avian & reptile panel Equine health Fib SAA Muscle enzymes Equine racing Electrolytes Production animal health Eye fluid panel Downer cow Add to panel: Avian & reptile health Pre-anaesthetic Liver Ammonia Kidney Copper Pancreas Iron Coagulation GPx PBFD (HA, serology & PCR) NEFA Add to profile: Other: Haematology Full blood count Fibrinogen Serum amyloid A Reticulocyte count (no FBC) Platelet count (only) Prothrombin time APTT Coomb’s test Cross match Blood typing IgG Other: Cytology General, body fluids Fine needle aspirate CSF analysis Bronchoalveolar lavage Trans-tracheal wash Other: Body Tissue, unfixed Tissue, fixed COLLECTION TIME: DATE: Microbiology Endocrinology Routine (aerobic) culture ACTH Progesterone Anaero-/microaerobic culture Cortisol Testosterone Blood culture Insulin Other: Faeces, bacteria only Total T4 n Faeces, prod animal panel canine TSH Milk culture & sensitivity Myoglobin Pre-breeding swab Troponin 1 Special culture for: HD dex suppression test LD dex suppression test Sensitivity Equine O/N dex supp. test Fungal, wet mount & culture Other: Pathology Necropsy, routine Parasitology Necropsy, legal/insurance Worm egg count, individual Tissue, gross pathology Worm egg count, pooled Histology Fluke egg count, individual Immunohistochemistry Fluke egg count, pooled Liver fluke antigen ELISA Faecal floatation Other tests: Total worm count for: Parasite ID Larval culture plus culture & sensitivity Urinalysis Urinalysis plus cytology plus culture & sensitivity Serology for: On behalf of the owner named above, I authorise Charles Sturt University Please copy results to: to use the samples that I have submitted and the results of the tests that I have requested for teaching and research, and to release the results to government agencies for in-confidence use. Signature: At VDL discretion to $200 $400 Date: $100 $