Favn Report Form - Rabies Antibody Titer For Export Animals - 2015

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FAVN REPORT FORM
RABIES LAB USE ONLY 
Rabies Antibody Titer for Export Animals
The Rabies Laboratory
Phone: 785-532-4483
Kansas State University
Fax : 785-532-4474
2005 Research Park Circle
Email: rabies@vet.k-state.edu
Manhattan, KS 66502
Results are reported on this form. Please complete on-line and printout. If handwritten, print clearly. Handwritten information is
*
Required fields are bolded.
subject to interpretation by laboratory personnel. Once submitted, information cannot be altered
.
HAWAII
Destination of animal being exported: ____________________________________________________
Destination information is for laboratory report distribution only.
Submitting Clinic: _______________________________________________ Phone: _____________________
Veterinarian Name: ______________________________________________ Fax: _______________________
Clinic Mailing Address: ___________________________________________ Email: ______________________
City: _________________________ State/Country: _________ / _______________ Zipcode:_______________
Owner Name: First ________________________ Last ________________________________________________
Animal Name: ________________________________________________________________________________
Microchip Number: ___________________________________ Serum Draw Date
_____/___/______
(mm/dd/yyyy):
If there are two microchip numbers, only the first one will be on the result label.
Species/Breed: ___________________________________________ Sex: M
F
Age:________________
Rabies Vaccination History:_________________________________________________________________________
Vaccination history is for laboratory reference only. Please include up to three recent vaccinations dates if available.
.
Samples and test data may be used for general research without compromising client confidentiality
Opt Out
Signature of Veterinarian: _________________________________________ Date
______/___/______
(mm/dd/yyyy):
Signature affirms that the above information is correct and the microchip number has been verified.
or
*.
Test will be cancelled if sample tube is unlabeled
arrives without the microchip number
RABIES LAB USE 
Payment Total: __________________________ 
STAT:            Courier: 
  Priority / 2‐Day / Ground / NBC 
For Lab Use Only:
Opened by: __________________________
Processed By: _______________________________
Transferred By: ______________________
Payment Received: ___________________________
*
Please see instructions for FAVN submission and reporting at . This submission form is a legal binding contract
between KSVDL and the submitting clinic. The submitting clinic is responsible for all fees incurred and is the recipient of the FAVN report. Please see
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 accessed on all
charges over 30 days.
Version 01/2015

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