Canine Export Submission Form - 2013
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1Canine Export Submission Form
Kansas State Veterinary Diagnostic Laboratory
1800 Denison Avenue, Mosier D117 Manhattan, KS 66506
Phone: (785) 532‐5650 Toll Free: (866) 512‐5650
Fax: (785) 532‐4835
BILL TO
Client
Owner
Third Party
Owner/Third Party to Receive Results?
Y
N
Third Party Contact Info:
Account#
________________ Internal Ref # ________________
OWNER/PRODUCER
Veterinarian:______________________________________________
Owner Name:_____________________________________________________
Farm Name:_______________________________________________________
Clinic Name: __________________________________________________________
Address:__________________________________________________________
Address:__________________________________________________
City, State:
Zip:___________________
City, State:
Zip: __________________
Phone:
Cell: ________________________
Phone:
Fax:_______________________
Fax or Email:______________________________________________________
Email: _______________
____ ___________________________
REQUIRED INFORMATION*
Please Mark Requested Tests:
*SPECIES
CANINE BRUCELLOSIS - SERUM
*ANIMAL NAME
EHRLICHIA CANIS - SERUM
*MICROCHIP #
LEPTOSPIRA CANICOLA - SERUM
*DATE BLOOD DRAWN ______ ______ _______
LEISHMANIA INFANTUM
SERUM
-
(MM)
(DD)
(YYYY)
OCCULT HEARTWORM (ANTIGEN)
SERUM
-
Country Being Sent To:
RESULTS (FOR LABORATORY USE ONLY)
KNOTT’S TEST (MICROFILARIAE)
1CC BLOOD IN PURPLE TOP TUBE
HEARTWORM DIFIL FILTER TEST
(MICROFILARIAE)
1CC BLOOD IN PURPLE TOP TUBE
*For Rabies Serology (FAVN) click
HERE
and then choose Test Submission Form
INSTRUCTIONS
A total of 1-2cc of clear (non-hemolyzed) serum is required for all tests, except Knott’s Testing and Heartworm DIFIL testing.
We recommend all samples be shipped overnight with cool packs.
Please fill out the form clearly and legibly, checking all information for accuracy.
It is the responsibility of the submitting party to varify testing requirements for exportation.
*ONCE THIS FORM IS COMPLETED AND SAMPLES SUBMITTED, THE INFORMATION WILL NOT BE CHANGED OR
ALTERED BY ANY PARTY. OMISSIONS OR ERRORS OF ANY REQUIRED INFORMATION WILL REQUIRE
RESUBMISSION OF ALL INFORMATION AND SAMPLES.
Please Note: Babesia gibsoni testing is NOT being performed at Kansas State Veterinary Diagnostic Laboratory.
This submission form is a legal and binding contract between KSVDL and the submitting entity. All fees, to include collection fees, are the responsibility of the submitting entity and all entities must adhere to the billing
policy. Fees may be paid by check (payable to KDAS), credit card, money order, or electronic bank transfer. A 1.5% finance charge will be assessed on all charges over 30 days 12/4/2013
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Parent category: Medical