Document 6535912

FACULTY OF SCIENCE
School of Animal and Veterinary Sciences
Veterinary Diagnostic Laboratory
SAMPLE SUBMISSION FORM
Locked Bag 588, Boorooma Street Phone: +61 2 6933 4000
Wagga Wagga NSW 2678 Australia
Fax: +61 2 6933 4348
ABN: 83 878 708 551
Email: vdl@csu.edu.au
ABN: 83 878 708 551
Veterinarian/Agent:
Animal ID:
Address:
Species:
Email:
Invoice (tick ):
Age:
Breed:
Ph:
Owner’s name:
Fax:
Owner’s address:
□ submitter □ CSU code __________________
Gender:
PIC:
HISTORY, SIGNS, LESIONS:
DIFFERENTIAL DIAGNOSIS: 1.
NUMBER of
SAMPLES
2.
n
3.
Blood, clotted
Blood, EDTA
Blood, hep
Swab
Faeces
Blood, citrate
Blood, fl/ox
Slide
Fluid
Other
TESTS REQUESTED (tick )
Biochemistry
Profiles
Canine & feline panel
Feline health
Equine panel
Canine health
Production animal panel
Greyhound racing
Avian & reptile panel
Equine health
Fib
SAA
Muscle enzymes
Equine racing
Electrolytes
Production animal health
Eye fluid panel
Downer cow
Add to panel:
Avian & reptile health
Pre-anaesthetic
Liver
Ammonia
Kidney
Copper
Pancreas
Iron
Coagulation
GPx
PBFD (HA, serology & PCR)
NEFA
Add to profile:
Other:
Haematology
Full blood count
Fibrinogen
Serum amyloid A
Reticulocyte count (no FBC)
Platelet count (only)
Prothrombin time
APTT
Coomb’s test
Cross match
Blood typing
IgG
Other:
Cytology
General, body fluids
Fine needle aspirate
CSF analysis
Bronchoalveolar lavage
Trans-tracheal wash
Other:
Body
Tissue, unfixed
Tissue, fixed
COLLECTION TIME:
DATE:
Microbiology
Endocrinology
Routine (aerobic) culture
ACTH
Progesterone
Anaero-/microaerobic culture
Cortisol
Testosterone
Blood culture
Insulin
Other:
Faeces, bacteria only
Total T4
n
Faeces, prod animal panel
canine TSH
Milk culture & sensitivity
Myoglobin
Pre-breeding swab
Troponin 1
Special culture for:
HD dex suppression test
LD dex suppression test
Sensitivity
Equine O/N dex supp. test
Fungal, wet mount & culture
Other:
Pathology
Necropsy, routine
Parasitology
Necropsy, legal/insurance
Worm egg count, individual
Tissue, gross pathology
Worm egg count, pooled
Histology
Fluke egg count, individual
Immunohistochemistry
Fluke egg count, pooled
Liver fluke antigen ELISA
Faecal floatation
Other tests:
Total worm count
for:
Parasite ID
Larval culture
plus culture & sensitivity
Urinalysis
Urinalysis
plus cytology
plus culture & sensitivity
Serology
for:
On behalf of the owner named above, I authorise Charles Sturt University Please copy results to:
to use the samples that I have submitted and the results of the tests
that I have requested for teaching and research, and to release the results
to government agencies for in-confidence use.
Signature:
At VDL discretion to
$200
$400
Date:
$100
$