Illinois Department of Agriculture
Bleeding date:________________________________
Accession number:_________________________
Serology Test Request Form (L4)
Total tubes submitted: _________________________
Page ________________ of ____________________
I certify that I have drawn blood samples from each animal identified below and have correctly listed
each tube number with the corresponding animal identification.
Owner: ___________________________________________________________
Veterinarian’s signature:_______________________________________________
Address: __________________________________________________________
Veterinarian’s name:__________________________________________________
City, ST ZIP: ______________________________________________________
Clinic name: ________________________________________________________
Location of animals:
Address ____________________________________________________________
Address: __________________________________________________________
City, ST ZIP: _______________________________________________________
City:________________________ County____________________ ST: ______
Telephone: (________) ________________ FAX: _________________________
Premises ID: ________________________________________________________
E-Mail:______________________________________ Results by E-Mail?
Purpose of test
Species
Diagnostic
Qualification #__________________
Cat
Dog
Pig
Complete herd test?
Sale/Show
Import retest # __________________
Cattle, beef
Goat
Sheep
Yes
No
Export
Other _________________________
Cattle, dairy
Horse
Other ____________
If you mark only Brucellosis or Pseudorabies box, we will select an appropriate test. If you need a special test (e.g., for export) mark the appropriate test box as well.
Anaplasmosis, cELISA___________
Pseudorabies
BVD
Leukosis, bovine
PCR, individ _________________
AGID_______________________
AutoLex____________________
Bluetongue
AGID_______________________
PCR, pooled__________________
cELISA______________________
gB ELISA___________________
cELISA______________________
Ear notch (fixed), IHC__________
M hyopneu ____________________
g1 ELISA (differential)________
Brucellosis
Neospora, cELISA_______________
Salmonella pullorum/typhimurium
EIA- Use federal form VS-10-11
B canis, card
Swine influenza_______________
Johne’s
PRRS
BAPA _______________________
Culture______________________
ELISA _____________________
Other________________________
Card ________________________
ELISA (serum)________________
IFA US _____________________
Comments:______________________
RAP _______________________
PCR, individ__________________
IFA Lelystad _________________
_______________________________
Rivanol _____________________
PCR, pooled__________________
PCR, Pooled__________________
_______________________________
Std plate _____________________
PCR, Indiv___________________
________________________________
Std tube_____________________
________________________________
Tube
Identification
Age
Breed
Sex
Tube
Identification
Age
Breed
Sex
1
6
2
7
3
8
4
9
5
10
ADL FORM OFF.L4 Revision 8 (04Feb16)