Form F-Addl-Adm-026 - Addl Sample Submission - Animal Disease Diagnostic Laboratory
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1
2Animal Disease Diagnostic Laboratory
8995 East Main Street
Reynoldsburg, Ohio 43068
Phone: (614) 728-6220
Fax:
(614) 728-6310
ADDL SAMPLE SUBMISSION FORM
Vet License #
Clinic Premises #
Premises #
Date collected
Date shipped
Owner's Name
Submitter's Name
Farm Name
Clinic Name
Address
Address
City
State
Zip
City
State
Zip
County
Phone
Phone
FAX
Bill will be sent to the clinic.
RESULTS
Email Address
Diagnostic sample
FAX
Export sample
Country :
Mail
Program sample: PRV Brucella NPIP Johne's EIA (EIA requests must be accompanied by form 0251) CWD
Cattle
Cat
Herd/Flock ID
Grower House #
Layer/Finisher #
Horse
Turkey
Swine
Chicken
Epidemiologic Info: # in herd/flock
# in group
# sick
# dead
Sheep
Psittacine
Goat
Ratite
Date died
Euth? Yes No Abortion: trimester
Age of Dam
Dog
Other:
History (clinical signs, nutrition, housing, vaccination, treatments, production level, related accessions, etc.):
(Continue on back if necessary)
Request antimicrobial susceptibility on bacterial pathogens.
Disease(s) or condition(s) suspected:
I authorize the ADDL to use discretion to perform appropriate tests.
Sample Data:
NO.
ANIMAL ID
BREED
SEX
AGE
QTY
SPECIMEN
TEST(S) REQUESTED
I certify that I have collected these samples and
officially identified the animals indicated.
History (continued on Page 2)
Signature of Licensed Veterinarian
Accredited
F-ADDL-ADM-026 r.5
Page 1 of 2
Authorized by: QAM
Effective Date: 04/28/2010
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