RCVF 54 Accession Form by thI762H

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									                         Veterinary Medical Diagnostic Laboratory
               College of Veterinary Medicine, University of Missouri-Columbia            For Lab Use Only
                                                                                          VMDL Accession No. :
                1600 E. Rollins St., Columbia, MO 65211 (UPS, FedEx, Etc.)
                                                                                          MU-VTH No. _________________________________
                    P.O. Box 6023, Columbia, MO 65205 (U.S. Mail Only)
                                                                                          Delivered By Owner _________ Vet _________
                  Telephone: 573-882-6811 or Toll Free 1-800-UMC-VMDL                     US Mail □ UPS □        FedEx □     Courier □
                    Fax: 573-882-1411 www.cvm.missouri.edu/vmdl

Acct No.                                                                         Date Sample Taken ____________Date Submitted ________
Phone                          Fax:
Veterinarian: Dr.                                                                Owner ___________________________________________
Clinic                                                                           Farm/Company_____________________________________
Address                                                                          Address ___________________________________________
City, State Zip                                                                  City______________________ State_________ Zip________
Client/Third Party ____________________________________                          Phone:
Company ____________________________________________
Address ______________________________________________                           Bill to Vet _____ Owner ____ Client/Third Party ____
City __________________________State _________Zip________                        Export Case Yes ____ No ____
Phone______________________ Fax _______________________                          Email report to: _____________________________________

History
Animal ID____________ Species ____________ Breed ______________ Sex_________ Age________ day mo. yr. Weight_______
Number in Group _______ Number Sick (excluding dead) _____ Number Dead _____        Raised on Premises? yes / no
If purchased, when?______________ Recent introductions? yes / no Date Introduced ________________
Date first noticed sick _____________ Euthanized? yes / no Method used ______________________________________________
Time & Date of Death _____________ Previous submissions? yes / no VMDL accession no. ___________
Clinical signs, vaccinations & dates & postmortem findings: __________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Field Diagnosis

If tumor Size ___________Duration________             Rate of growth: slow/fast Recurrence    yes / no
Site of lesion: Internal—Location in organ or tissue _____________External—Location on skin or mucous membrane ____________

Specimen Submitted         Qty          Examinations Requested
□ Live Animal            ______         □ Gross Necropsy only
                                                                                                             Sample Information
□ Dead Animal            ______         □ Gross Necropsy with Histopathology
□ Fetus                  ______         □ Necropsy with other labs
□ Blood                  ______         □ Histopathology *
□ Serum                  ______         □ Immunohistochemistry
□ Fixed Tissue           ______         □ Clinical Pathology (See reverse side)
□ Fresh Tissue           ______         □ Mycoplasma Isolation**
□ Milk                   ______           Bacteriology                                               R         L                L              R
□ Urine                  ______         □ E. coli Typing
□ Feces                  ______         □ Isolation/Identification**
□ Stomach Contents       ______         □ Aerobic Culture
□ Referral Plate         ______         □ Anaerobic Culture
□ Swab (original)        ______         □ Antimicrobial Susceptibility
□ Feed                   ______         □ Parasitology                                                   Ventral                     Dorsal
□ Water                  ______         □ Mycology
□ Other                  ______         □ Virology
                                                                                                     For Lab use only
□ Other                  ______         □ Virus Isolation __________                                 Sample Received __________________
                                        □ FA _______
 *fresh & frozen tissues not suitable   □ EM _______                                                 Processed by ______________________
**formalin fixed tissues not suitable   □ PCR______________________________________
                                        Serology (See reverse side)                                  Comments ________________________
                                        Toxicology-Specify Test _______________________


VMDL               SOP-#-F-#
                   RCV-F-54
                                                      FORM TITLE
                                                      VMDL Accession Form
                                                                                                                                  ISSUE DATE
                                                                                                                                  10/04/06
By submitting diagnostic specimens to the VMDL, clients are considered to have agreed to VMDL testing procedures and policies, including billing.
                                    Animal Identification                                            Date Bled ___________Resubmission yes/no
        Tube Name/No.                    Species         Breed               Sex   Age               Complete Herd Test Yes/No
1                                                                                                    Serology Tests
2                                                                                                    □  Anaplasmosis
                                                                                                     □  Blastomycosis
3
                                                                                                     □  Bluetongue
4                                                                                                    □  Bovine Leucosis Virus (BLV)
5                                                                                                    □  Bovine Virus Diarrhea (BVD)
                                                                                                     □  Brucellosis (Abortus)
6
                                                                                                     □  Brucellosis (Canis)
7                                                                                                    □  Canine Distemper IgG
8                                                                                                    □  Canine Distemper IgM
                                                                                                     □  Caprine Arthritis-Encephalitis (CAE)
9
                                                                                                     □  Coccidiomycosis
10                                                                                                   □  Cryptococcus
11                                                                                                   □  Equine Herpesvirus
                                                                                                     □  Equine Infectious Anemia
12
                                                                                                     □  Equine Viral Arteritis
13                                                                                                   □  Ehrichia canis
14                                                                                                   □  Ehrlichia ristici
                                                                                                     □  Feline Heartworm Antibody
15
                                                                                                     □  Feline Immunodifficiency Virus (FIV)
16                                                                                                   □  Feline Infectious Peritonitis (FIP)
17                                                                                                   □  Feline Leukemia Virus (FeLV)
                                                                                                     □  Histoplasmosis
18
                                                                                                     □  Infectious Bovine Rhinotracheitis (IBR)
19                                                                                                   □  Leptospirosis
20                                                                                                   □  Mycoplasma Hyopneumenia
                                                                                                     □  Neospora (Bovine)
21 Pertinent Clinical Information (source of sample, description of lesion, etc.):
                                                                                                     □  Occult Heartworm
22                                                                                                   □  Ovine Progressive Pneumonia (OPP)
23                                                                                                   □  Parainfluenza 3 (PI3)
                                                                                                     □  Paratuberculosis (Johne’s)
24
                                                                                                     □  Porcine Parvovirus (PPV)
25                                                                                                   □  Porcine Reprod Resp Synd Virus (PRRS)
26                                                                                                   □  Pseudorabies Virus (PRV)
                                                                                                     □  Rocky Mountain Spotted Fever
27
                                                                                                     □  Swine Influenza H1N1 & H3N2
28                                                                                                   □  Toxoplasmosis
29                                                                                                   □  Transmissible Gastroenteritis (TGE)
                                                                                                     □  Vesicular Stomatitis - IN or NJ
30
                                                                                                     □  West Nile Virus
31                                                                                                   □ _________________________
                                                                                                     Collect specimens in sterile vacutainer tubes without
                                                                                                     anticoagulant, Brucellosis tubes are not satisfactory.

CLINICAL PATHOLOGY Date Sample Taken _________________
                                                                                                 Fecal Examination
Chemistry                                            Hematology (EDTA)                           □ Flotation □ Other (specify) ________________
Specimen—Do not send whole blood                     □ CBC - Submit EDTA tube & smears           For Courier or Local Samples Only
□ Serum □ Plasma □ Other ___________                 □ Buffy Coat for __________________         □ Voided □ Catheter □ Cysto. □ Off Floor
                                                     □ Smear Exam for _________________          □ Complete UA
□ MAXI Profile □ LIVER Profile                       □ Other (specify) __________________        □ UA w/o Sediment Exam
□ MINI Profile □ Other (specify) _________           ________________________________              Coagulation—Call for instructions

Cytologic Examination—Label slides with animal ID & site                            Fluid Analysis (includes Cytologic Exam)
□ Washes □ Aspirates □ Imprints □ Brushes                                           Please Submit Slides with Fluid
□ Scrapings □ Other (specify) _______________________                               □ CSF □ Pleural □ Peritoneal □ Synovial □ Pericardial
Pertinent Clinical Information (source of sample, description of lesion, etc.): ___________________________________________________________
___________________________________________________________________________________________

     VMDL            SOP-#-F-#
                     RCV-F-54
                                                       FORM TITLE
                                                       VMDL Accession Form
                                                                                                                                       ISSUE DATE
                                                                                                                                       10/04/06
     By submitting diagnostic specimens to the VMDL, clients are considered to have agreed to VMDL testing procedures and policies, including billing.

								
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