Serology And Multiple-Test Submission Form - Wisconsin Veterinary Diagnostic Laborarory

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NEW ACCOUNT



SEROLOGY & MULTIPLE-TEST SUBMISSION FORM

For Laboratory Use Only

 Frozen

 Chilled

 Warm

E-MAIL

MADISON

BARRON

445 Easterday Lane

1521 E. Guy Avenue

info@wvdl.wisc.edu

Madison, WI 53706

Barron, WI 54812-0097

LABEL

Phone: (800) 608-8387

Phone: (800) 771-8387

WEBSITE

FAX: (608) 504-2594

FAX: (715) 449-5052

*Required field

Reason for Test*

OWNER* _____________________________________

VETERINARIAN* ___________________________________



Herd Certification

Sale

Farm __________________________________________

License No.* _________________________________________



Diagnostic

Show

Address*_______________________________________

Clinic* _____________________________________________



Abortion

Biosecurity

City* __________________________________________

Clinic Acct. No. ______________________________________



Pre Purchase

Screening/

State* __________________

Zip _____________

Address* ____________________________________________

Report as Tested



Johnes Classification

Premise ID _____________________________________

City* __________________

State* _____

Zip __________

_____ Complete Herd

______________________________________________

Clinic Premise ID _____________________________________

_____ Random Herd

Date samples taken* ______________________________

E-MAIL* ___________________________________________

_____ Split Herd, Final? Yes

Date samples shipped* ____________________________

Phone* __________________

FAX* ___________________



Retest-prior accession # ______________

No. of test eligible animals in herd __________

____________________________________________________________

SUBMITTING VETERINARIAN’S SIGNATURE*

(Signature indicates that specimen(s) were collected by or under the supervision of the signing veterinarian.)

INTERNATIONAL TO: ____________________

INTERSTATE TO: ________________________

SPECIES __________________________

BREED _________________________

PAGE _____ OF _____

OFFICIAL IDENTIFICATION*

SEX

AGE

Anapl.

Bruc.

Johnes

Lepto.

BLV

BTV

Ind.

BVD

BTV

EHD

IBR

NEO

OTHER

(Must match ID on tubes.)

BAPA

STT

cElisa

Other

MAT

add. ser.

AGID

BTV

AGID

BVD

PCR

ELISA

EHD

AGID

______

cELISA

ELISA

M / F

Yrs. / Mos.

SPT

_____

ELISA

6 ser.

_______

PCR

Pool

1,2

ELISA

Screen

ELISA

PCR

1,2

NJ, Ind.

_______

OIE

________________________________________________________________________________________________________________________________________________________________________________

10.

________________________________________________________________________________________________________________________________________________________________________________

11.

________________________________________________________________________________________________________________________________________________________________________________

12.

NOTE: Please indicate testing requests clearly. Circle test choice when more than one testing option is listed within a column.