General Sample Submission Form

General

Sample

Submission

Form

Veterinarian:

Clinic:

Address:

City:

Phone:

FedEx/UPS/Drop Off Address: CSU Veterinary Diagnostic Laboratory

2450 Gillette Drive

Fort Collins, CO 80526

Phone: 970-297-1281

Fax: 970-297-0320

www.dlab.colostate.edu

State: Zip:

Owner/Producer:

Address:

Zip:State:

Business/Premise ID:

City:

Phone:

Person to be Billed: Veterinarian Owner/Producer Report Results To: Owner/ProducerVeterinarian

Fort Collins, CO 80523-1644

200 West Lake Street

USPS Only Address: CSU Veterinary Diagnostic Laboratory

VTH USE ONLY (Patient Card Here)

Clinician/Resident:_______________________________________________

Pager: ___________________________ H-Account/Fund: __________________

OFFICE USE ONLY

Opened By:

DHL USPS FX Courier Other

Frozen Dry Ice Ice Pack RT Other Fixed

Sample Type(s): Comments:

Phone:Email:Fax:

Send Results By:

STAT -- Additional Charge, Contact Lab for Pricing

Age

Environmental (specify): Additives/Media Used:

Semen

Swab (specify):

Wildlife/Exotic (specify):

Animal Name/ Number/ ID Breed Sex Collection Date

HISTORY (include clinical signs, differential diagnoses, antibiotic use, vaccine history, duration, number of animals affected, etc.) If more space is

needed, please continue on and attach an additional page.

Specimen(s)

ANIMAL IDENTIFICATION (if >3 samples, continue on Multiple Animal Submission Form)

Results Phoned/Faxed/Emailed Date ________________ Initials _______

Other (specify):

Whole Body

Whole Blood

Fetus

Serum Culture Plate Isolate FecesUrineMilk

Tissue(s) (specify):

Avian (specify):

Equine

Bovine Camelid CaprineCanine

Feline Ovine Porcine

Reptile/Amphibian (specify):

Other (specify):

Last Updated 10/7/2019 JBD

1644 Campus Delivery

Separate submission forms are required for Clinical

Pathology, Clinical Immunology and Necropsy.

PANELS/SCREENS -- See User Guide for tests included

OFFICE USE ONLY

Abortion Serology Panel

Vet:

CEM** Culture

AVIAN DIAGNOSTICS (if more than one test type is listed, please circle desired test)

Salmonella Enteritidis PCR

Clostridium perfringens Enterotoxin

Blood Culture**

Clostridial Fecal Culture Mycobacterium Culture

Urine Culture

Bacillus anthracis PCR

Abortion Screen Diarrhea Screen

Respiratory Serology Panel

APMV-1 (NDV) (PCR / VI / HI / ELISA)

Influenza (PCR / VI / HI / AGID / ELISA)

Psittacosis (Chlamydophila) PCR

Anaerobic Culture** of

Antibiotic Susceptibility

BACTERIOLOGY (if more than one test type is listed, please circle desired test)

Serology

General

Cryptococcus Serology

Fungal Serology Panel

Immunofixation

Protein Electrophoresis

(Aspergillus/Histoplasma/

Blastomyces/Coccidioides)

VIROLOGY/VIROLOGY SEROLOGY (if more than one test type is listed, please circle desired test)

Rotavirus ELISA

Rabies FA

General

BVD I & II (SN / PCR)

BHV-1 (IBR) (SN / FA / PCR / VI)

Bovine

BRSV (SN / FA / PCR / VI)

PI3 (SN / FA / VI)

BCV FA

BVD (FA / VI / ELISA)

BTV (AGID / PCR)

Chlamydophila PCR

VSV - IND/NJ (SN / CF)

BLV (AGID / PCR)

Brucella spp. PCR

Campylobacter Culture

Francisella tularensis PCR

Leptospirosis PCR

Mycoplasma** (Culture / PCR)

Q Fever (C. burnetii) (PCR / ELISA

Bovine Camelid Canine Equine Feline Ovine/Caprine

Canine

CHV (Herpesvirus) (SN / FA / PCR)

Influenza (HI / PCR)

CDV (SN / FA / PCR)

CDV IgG/IgM IFA

CPV-2 (HI / FA / PCR / SNAP ELISA)

FIP (FA / IFA / PCR)

FIV/FeLV SNAP ELISA

FIV PCR

FCV (SN / PCR)

FHV/Chlamydophila Duplex PCR

FPV (HI / FA / PCR / SNAP ELISA)

FHV SN

EquineFeline

VSV - IND/NJ (SN / CF)

WEE PCR

Influenza (HI / PCR)

EVA (SN / PCR / VI)

EHV-3 (SN / PCR)

EHV-4 SN

EHV 1 & 4 PCR

EHV-1 (SN / FA)

WNV (IgM ELISA / PCR)

Camelid

BVD I & II (SN / PCR)

BVD (SN / FA / VI)

Ovine/Caprine

OPP (AGID / PCR)

OHV-2 (MCF) PCR

CAE (AGID / PCR)

Caprine Herpesvirus PCR

Chlamydophila PCR

BTV (AGID / PCR)

Porcine

CSFV PCR

Influenza (HI / PCR)

PRRS PCR

TGE (SN / FA)

ANA

IgA Quant

IgG Quant

Lepto-5 MAT

IgG Estimate

IgG Quant

Johne's ELISA

Brucella abortus

Lepto-5 MAT

IgM Quant

Brucella canis

IgA Quant

IgG Quant

ANAIgG Estimate

IgG Quant

Brucella

Brucella abortus

Brucella (caprine)

Johne's AGID

IgG SNAP

IgM Quant

Lepto-5 MAT

IgG Quant

Lepto-5 MAT

M. synoviae plate test

M. gallisepticum/M. synoviae PCR

M. gallisepticum (plate test / ELISA)

WNV PCRSalmonella - mortality

Pullorum/Typhoid plate test

Salmonella - environmental

PARASITOLOGY & PARASITOLOGY COMBINATIONS (if more than one test type is listed, please circle desired test

Trichinella Digest

Soil Analysis

Occult Blood

Parasite Identification (Internal / External)

Fecal Flotation

General

Pinworm (Cellophane Tape Technique)

Equine

Microfilaria (Knott's Test)

Heartworm serology

Canine/Feline

** Special Media Required; Please Contact Laboratory

CCV FA

EIA (AGID / ELISA) *Special Form Required*

Ruminant/Camelid

Ehrlichia/Lyme/Anaplasma/Heartworm Screen

Ehrlichia canis IFA (titer)

Ehrlichia/Anaplasma/Neorickettsia PCR

RMSF IFA (titer)

Haemoplasma spp PCR

Sedimentation (flukes)

Cryptosporidium/Giardia IFA

Cryptosporidium acid fast (bovine only)

Toxoplasma gondii PCR

Neospora cELISA

T. foetus/Trichomonads (Culture - Diamonds / Culture - InPouch / PCR)

ENDOCRINOLOGY

Thyroid Panel (T4, eTSH, TGAA ELISA)

Dexamethasone Suppression (low or high dose)

ACTH Stimulation (pre/post)

Phenobarbital Concentration

Endogenous ACTH

Insulin Concentration

Total T4

Canine

Total T4

Insulin Concentration

Endogenous ACTH

Dexamethasone Suppression (low or high dose)

ACTH Stimulation (pre/post)

Equine

Insulin Concentration

Total T4

Feline

Histopathology

PATHOLOGY

Clinical Dermatology Consultation (Additional Fee)

Necropsy (separate form required)

2nd Opinion Histopathology

IHC forEndometrial Biopsy

Histopath Mailers Needed

CHEMISTRY/TOXICOLOGY

Iron

Zinc

SeleniumCopper

Vitamin E

Bromide

CalculiVitamin A

Lead

Arsenic

MercuryNitrate

w/Histo

Animal ID:

Owner:

Species:

Other (please specify test & species):

Other:

Pathologist Requested

Fecal Screen - Includes float, direct, IFA

Baermann (Qualitative / Quantitative)

T. foetus (Culture - InPouch / PCR)

Bartonella spp. (PCR / ELISA - feline only)

Neospora caninum (IFA / PCR)

Toxoplasma gondii (IgG-IgM ELISA / PCR)

with Ehrlichia/Anaplasma/Neorickettsia PCR

Toxoplasma gondii MAT - non canine/feline

Bartonella spp. PCR plus ELISA

Canine Fever/Blood Donor Panel - Ehrlichia/Bartonella/Haemoplasma/Rickettsia PCR

Basal Cortisol

Aerobic Culture of

Fungal Culture

Canine adenovirus-1 (ICH) & 2 PCR

CPV-1 (Minute virus) PCR

Respiratory Screen

PRV ELISA

BTV PCR

EHD PCR

Infectious Bronchitis Virus (IBV) ELISA

Other (please specify test & species):

Rickettsia spp. PCR

Other (please specify test & species):

Conjunctivitis Panel

Cryptosporidium PCR

Giardia ELISA

IFA with Rickettsia spp. PCR

Feline Fever Panel - Hemoplasma/Ehrlichia/Bartonella PCR with Toxo ELISA and Bartonella ELISA

Feline Blood Donor Panel - Hemoplasma/Ehrlichia/Bartonella PCR

BVD (SN / FA / VI)

Mast Cell Tumor Profile

Giardia PCR

Piroplasmosis cELISA (T. equi & B. caballi)

Yersinia pestis (plague) PCR

Streptococcus equi PCR

Liver Panel (Histo, Copper Quant & Special Stains)

C. perfringens Genotyping PCR

Enzootic Nasal Tumor Virus PCR

Jaagsiekte Sheep Retrovirus PCR

BHV-5 PCR

BHV-4 PCR

Milk submissions - *Use 'Milk Sample Submission Form'*