Form Off.l4 - Serology Test Request Form (L4) - Illinois Department Of Agriculture

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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___________________