Equine Piroplasmosis Submittal Form - Oklahoma Animal Disease Diagnostic Laboratory

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REC-FM-023.02
Oklahoma Animal Disease Diagnostic Laboratory
1950 W. Farm Rd. Stillwater, OK 74078 (UPS, FedEx, Etc.)
P.O. Box 7001, Stillwater, OK 74076 (US Mail Only)
405.744.6623
405.744.8612
PHONE
FAX
EQUINE PIROPLASMOSIS SUBMISSION FORM
CERTIFICATION OF FEDERALLY ACCREDITED VETERINARIAN
I certify the specimen submitted with this form was drawn by me from the horse described below on the date indicated below.
OWNER LAST NAME
FIRST
INITIAL
VETERINARIAN PRINTED NAME
USDA Accreditation #
OWNER ADDRESS
VETERINARIAN SIGNATURE
CITY
STATE
ZIP
CLINIC ADDRESS
OWNER PHONE
CITY
STATE
ZIP
NAME AND ADDRESS OF STABLE/TRAINER
CLINIC PHONE
FAX
OWNER ADDRESS
CELL PHONE
CITY
STATE
ZIP
EMAIL
CLINICAL ILLNESS*
INTERSTATE TRAVEL
REASON FOR TEST:
EXPORT*
BREED/RACE/SHOW/SALE
* Clinical Illness and Export samples will be forwarded to NVSL
TEST REQUESTED
T. equi
B. caballi
DATE BLOOD DRAWN (MM/DD/YYYY)
TUBE NO.
OFFICIAL TAG NO.
PERMANENT ID: BRAND/MICROCHIP/TATTOO
NAME OF HORSE
COLOR
BREED
DOB or AGE
SEX
STALLION
GELDING
MARE
NARRATIVE DESCRIPTION AND REMARKS
HEAD
OTHER MARKINGS AND BRANDS
LEFT FORELIMB
RIGHT FORELIMB
LEFT HINDLIMB
RIGHT HINDLIMB
LABORATORY USE ONLY
1 Mail-post mark _____________
Receipt Record
Miscellaneous Fees
Receipt Condition
Opened By
1 UPS
1 Vet
1 Good
1 Leaked
1 Postage Due _____
1 FedEx
1 Owner
1 Frozen
1 Dry Ice
1 Courier
1 Other
1 Broken
1 Crushed
1 Return Box ______
1 No Refrigeration
1 DHL
1 Cold Pack
G:\SOPS\Receiving\forms\EP Submittal REC-FM-023.02.pdf

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