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
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