Reportable Disease Case Report Form - Colorado Department Of Agriculture

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REPORTABLE DISEASE CASE REPORT FORM
Colorado Department of Agriculture
Phone: (303)869-9130
Animal Health Division
Fax:
(303)466-8515
305 Interlocken Parkway
Hours: Mon – Fri 8am – 5pm
Broomfield, CO 80021-3484
After hours: Phone message will indicate staff veterinarian on call
Veterinarian:
Clinic:
Date:
Veterinarian Phone:
Veterinarian Email:
Animal Owner:
Owner Phone:
Owner Address:
Owner Email:
Species:
Breed:
Age:
Sex:
Animal Purpose:
Animal Name
:
Official ID:
(if applicable)
Animal Address
:
County:
(if different than owner)
Clinical diagnosis or suspected conditions:
Clinical signs:
Date of onset:
History:
Treatment:
Yes
No
If yes, summarize treatment:
Animal Status:
Dead
Euthanized
Alive
Recovering
Number (and species) of animals affected:
Other animals on premises:
Tests requested:
Date Submitted:
Laboratory:

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