OFFICE USE ONLY
General
Sample
Submission
Form
www.dlab.colostate.edu
Phone: 970-297-1281
Fax: 970-297-0320
Mailing Address:
Print Form
Opened By:
DHL
USPS
Frozen
FX
Dry Ice
Courier
Ice Pack
Other
RT
Other
Sample Type(s):
Comments:
VTH USE ONLY (Imprint Patient Card Here)
CSU Veterinary Diagnostic Laboratory
200 West Lake Street
1644 Campus Delivery
Fort Collins, CO 80523-1644
Physical Address: CSU Veterinary Diagnostic Laboratory
300 West Drake Road
Fort Collins, CO 80526
Clinician/Resident: ____________________________________________________
Student: ___________________________ H-Account/Fund: __________________
Veterinarian:
Owner/Producer:
Clinic:
Business/Premise ID:
Address:
Address:
City:
State:
Zip:
City:
Phone:
State:
Zip:
Phone:
Person to be Billed:
Send Results By:
Veterinarian
Report Results To:
Owner/Producer
Fax:
Email:
Avian (specify):
Feline
Owner/Producer
Phone:
Bovine
Equine
Veterinarian
Camelid
Ovine
Porcine
Wildlife/Exotic (specify):
Canine
Caprine
Reptile/Amphibian (specify):
Other (specify):
Specimen(s)
Whole Blood
Serum
Semen
Culture Plate Isolate
Fetus
Environmental (specify):
Whole Body
Milk
Swab (specify):
Urine
Feces
Tissue(s) (specify):
Other (specify):
Additives/Media Used:
ANIMAL IDENTIFICATION (if >3 samples, continue on Multiple Animal Submission Form)
Animal Name/ Number/ ID
Breed
Age
Sex
Collection Date
HISTORY (include clinical signs, differential diagnoses, antibiotic use, vaccine history, duration, number of animals affected, etc.) If more space is
needed, please continue on and attach an additional page.
SEND-OUT to ___________________________ for______________________
Results Phoned/Faxed/Emailed Date ________________ Initials _______
Last Updated 6/21/2011 cbw
OFFICE USE ONLY
Owner:
Vet:
Animal ID:
Print Form
Species:
Separate submission forms are required for Clinical
Pathology, Clinical Immunology and Necropsy.
PANELS/SCREENS -- See User Guide for tests included
Abortion Screen
Abortion Serology Panel
Conjunctivitis Panel
Diarrhea Screen
Respiratory Screen
AVIAN DIAGNOSTICS (if more than one test type is listed, please circle desired test)
M. gallisepticum (plate test / ELISA)
M. synoviae plate test
M. gallisepticum/M. synoviae PCR
APMV-1 (NDV) (PCR / VI / HI / ELISA)
Influenza (PCR / VI / HI / AGID / ELISA)
Infectious Bronchitis Virus (IBV) ELISA
Serology
General
Blood Culture**
Brucella spp. PCR
Campylobacter
CEM**
Bovine
Cryptococcus Serology
Fungal Serology Panel
(Aspergillus/Histoplasma/
Blastomyces/Coccidioides)
Camelid
Brucella
IgG Estimate
IgG Quant
Johne's ELISA
Lepto-5
Immunoeletrophoresis
Protein Electrophoresis
Lepto PCR
Mycobacterium Culture
Mycoplasma** (Culture / PCR)
Q Fever (Coxiella burnetii) PCR
Yersinia pestis PCR
Clostridial Enterotoxin
Clostridial Fecal Culture
Francisella tularensis PCR
Fungal Culture
Canine
C-Titer
IgG Estimate
IgG Quant
Lepto-5
Equine
ANA
Brucella canis
IgA Quant
IgG Quant
IgM Quant
Lepto-5
Feline
Brucella
IgA Quant
IgG Quant
IgG SNAP
IgM Quant
Lepto-5
Bovine
IBR (SN / FA / PCR / VI)
BVD I & II (SN / PCR)
BVD (FA / VI / ELISA)
BRSV (SN / FA / PCR / VI)
PI3 (SN / FA / VI)
BCV FA
BLV (AGID / PCR)
BTV (AGID / PCR)
Chlamydophila PCR
VSV - IND/NJ (SN / CF)
Canine adenovirus-2 PCR
Canine adenovirus-1 (ICH) PCR
CCV FA
CDV (SN / FA / PCR)
CDV IgG/IgM IFA
CPV-1 (Minute virus) PCR
CPV-2 (HI / FA / PCR / SNAP ELISA)
CHV (Herpesvirus) (SN / FA / PCR)
Influenza (HI / PCR)
CSFV PCR
Influenza (HI / PCR)
PRRS PCR
PRV ELISA
TGE (SN / FA)
Ruminant/Camelid
/
Feline
Canine
CHEMISTRY/TOXICOLOGY
Copper
Iron
Zinc
PATHOLOGY
w/Histo
w/Histo
w/Histo
Dexamethasone Suppression (low or high dose)
Panel (T4, eTSH, TGAA ELISA)
Basal Cortisol
Selenium
Vitamin A
Vitamin E
Histopathology
Pathologist Requested
Clinical Dermatology Consultation (Additional Fee)
Camelid
BVD I & II (SN / PCR)
BVD (SN / FA / VI)
Other (please specify test & species):
Equine
PCR)
ENDOCRINOLOGY
Total T4
Insulin Concentration
Endogenous ACTH
Phenobarbital Concentration
ACTH Stimulation (pre/post)
EHV-1 (SN / FA)
EHV-3 (SN / PCR)
EHV-4 SN
EHV 1 & 4 PCR
EVA (SN / PCR / VI)
EIA (AGID / ELISA) *Special Form Required*
Influenza (HI / PCR)
VSV - IND/NJ (SN / CF)
WEE PCR
WNV (IgM ELISA / PCR)
Pinworm (Cellophane Tape Technique)
Heartworm serology
Piroplasmosis ELISA
Microfilaria (Knott's Test)
Giardia ELISA
T. foetus/Trichomonads (Culture - Diamonds / Culture - InPouch / PCR)
Ehrlichia/Lyme/Anaplasma/Heartworm Screen
Ehrlichia canis IFA (titer)
with Ehrlichia/Anaplasma/Neorickettsia PCR
Ehrlichia/Anaplasma/Neorickettsia PCR
Bartonella spp. (PCR / ELISA - feline only)
Bartonella spp. PCR plus ELISA
Haemoplasma spp PCR
Feline Fever Panel - Hemoplasma/Ehrlichia/Bartonella PCR with Toxo ELISA and Bartonella ELISA
Feline Blood Donor Panel - Hemoplasma/Ehrlichia/Bartonella PCR
Canine Fever/Blood Donor Panel - Ehrlichia/Bartonella/Haemoplasma/Rickettsia PCR
Toxoplasma gondii (IgG-IgM ELISA / PCR)
Neospora caninum (serology / PCR)
RMSF IFA (titer)
IFA with Rickettsia spp. PCR
Rickettsia spp. PCR
Other (please specify test & species):
Fecal Flotation
Fecal Screen - Includes float, direct, IFA
Parasite Identification (Internal / External)
Occult Blood
Soil Analysis
Trichinella Digest
Toxoplasma gondii serology - non canine/feline
Cryptosporidium PCR
Giardia PCR
Cryptosporidium/Giardia IFA
Sedimentation (flukes)
Cryptosporidium acid fast (bovine only)
Toxoplasma gondii PCR
Neospora ELISA
T. foetus (Culture - Diamond's / Culture - InPouch
Porcine
Equine
Ovine/Caprine
PARASITOLOGY & PARASITOLOGY COMBINATIONS (if more than one test type is listed, please circle desired test
General
Baermann (Qualitative / Quantitative)
Canine/Feline
Brucella (caprine)
Johne's AGID
Brucella
FHV SN
FCV (SN / PCR)
FHV/Chlamydophila Duplex PCR
FPV (HI / FA / PCR / SNAP ELISA)
FIP (IFA / PCR)
FIV/FeLV SNAP ELISA
FIV PCR
BTV (AGID / PCR)
BVD (SN / FA / VI)
CAE (AGID / PCR)
Caprine Herpesvirus PCR
Chlamydophila PCR
OPP (AGID / PCR)
OHV-2 (MCF) PCR
Porcine
Ovine/Caprine
ANA
IgA Quant
IgG Quant
IgM Quant
Other (please specify test & species):
** Special Media Required; Please Contact Laboratory
VIROLOGY/VIROLOGY SEROLOGY (if more than one test type is listed, please circle desired test)
General
Canine
Feline
BTV PCR
EHD PCR
Rabies FA
Rotavirus ELISA
Salmonella Enteritidis PCR
Pullorum/Typhoid plate test
WNV PCR
Psittacosis (Chlamydophila) PCR
Salmonella - environmental
Salmonella - mortality
BACTERIOLOGY (if more than one test type is listed, please circle desired test)
General
Aerobic Culture of
Anaerobic Culture** of
Antibiotic Sensitivity
Bacillus anthracis PCR
Respiratory Serology Panel
Bromide
Calculi
Nitrate
Equine
Total T4
Insulin Concentration
Lead
Arsenic
Mercury
Necropsy (separate form required)
2nd Opinion Histopathology
Uterine Biopsy
ACTH Stimulation (pre/post)
Dexamethasone Suppression (low or high dose)
Endogenous ACTH
Insulin Concentration
Total T4
Basal Cortisol
Other:
Histopath Mailers Needed
Mast Cell Tumor Profile
IHC for