Oklahoma Animal Disease Diagnostic Laboratory

REC-FM-001.05
Oklahoma Animal Disease Diagnostic Laboratory
PO Box 7001, Stillwater, OK 74076 (US Mail only)
1812 Farm Rd. Stillwater, OK 74078
Phone: 405-744-6623 Fax: 405-744-8612 www.cvhs.okstate.edu
________________________________
OADDL Accession #
CLIENT INFORMATION
Owner
OADDL Account #
Farm Name
Veterinarian
Premise ID
Clinic Name
Address
Address
City
State
Phone #
Zip
City
Cell #
State
Phone #
Email
Zip
Fax #
Email
Bill to:
Veterinarian
Owner
Third party (see back)
Report to:
Veterinarian
Owner
Clinic
Method:
Yes
Rabies Suspect
Yes
Legal
Insured
Signature of Submitter/Date:
Animal ID
Date Collected:________________________
SIGNALMENT / HISTORY / CLINICAL SIGNS
Breed
Sex
M
Yes or
Email
Mail (add’l charge)
Yes
Printed Name of Submitter:
Species
Euthanized?
Fax
No, Method:
F
MC
FS
Age
Weight (lb)
Date:___________
Attach additional pages if needed.
SPECIMEN(S) SUBMITTED (indicate quantity submitted in the boxes below)
# Fresh
# Fixed
#Fresh
#Fixed
Whole Animal
Biopsy (location; see back)
Ear Notch
Lymph Node
Intestine
Stomach
Heart
Lung
Liver
Kidney
Spleen
Brain
______________
______________
Swab (source)__________________
Smear (source)_________________
Blood, clotted
Blood, unclotted
Serum
Trich Pouch
Aqueous / Ocular fluid
Urine
Cysto
Voided
Catheter
Stomach or
Rumen Contents
Feed
Water
TEST(S) REQUESTED (see fee schedule for complete list of tests)
Necropsy
Histopathology ( see back)
Short or
Virology
Detailed report
Clinical Pathology (Antech)
CBC
Profile
Other
Cytology (Antech)
Parasitology
Rabies
Abortion Panel
Diarrhea Panel
Serology (see back)
Toxicology (see back)
Avian Influenza PCR
Bluetongue PCR
Bovine Coronavirus PCR
BVD PCR
Canine Distemper PCR
Canine Parvovirus PCR
Campylobacter (Campy) culture
Salmonella culture
CEM culture
Bacterial/Fungal ID- DNA sequencing
Anaplasma marginale PCR
Cytauxzoon felis PCR
Clostridium perfringens PCR
Fluorescent Antibody (FA)
Rotavirus ELISA
BVD ELISA (antigen test)
serum
ear notch (fresh)
Virus Isolation
Bacteriology/Mycology
Aerobic culture
Sensitivity
Anaerobic culture
Fungal culture
Mycoplasma culture
Trich culture
Trich PCR
Clostridial FA test
LAB USE ONLY
RECEIPT RECORD
FedEx
Vet
USPS post mark____________
Postage Due_______________
UPS
Owner
Drop box
Other________________________________
LAB ASSIGNMENTS:
P
H
G:\SOPS\Receiving\forms\OADDL submittal REC-FM-001.05.doc
B
My
S
T
CONDITION UPON RECEIPT
Good
Broken
Frozen
Leaked
Cold Pack
No refrigeration
V
Mo
Mp
R
Antech
Exotic Newcastle Disease PCR
Epizootic Hemorrhagic Disease PCR
Equine Herpesvirus 1&4 PCR
General Herpesvirus PCR
Other PCR_________________
Johnes PCR
Leptospira sp. PCR
Mycoplasma bovis PCR
Streptococcus equi (Strangles) PCR
Other PCR_________________
REC-FM-001.05
SEROLOGY TESTS REQUESTED
THIRD PARTY INFORMATION (from front)
Name
Address
City
State
Zip
Phone
Fax
Sample Information: use additional sheet(s) if needed
#
ID
Species
Breed
Sex
Age
1
2
3
4
5
6
7
Anaplasmosis c-ELISA
Bluetongue c-ELISA
Bovine Leukemia ELISA
BRSV SN (antibody)
BVD SN (antibody)
BVD ELISA (see Virology)
Brucella abortus
(only official for swine)
Brucella canis
card or
IFA
CAE c-ELISA
Canine Distemper SN
Canine Parvo IFA
EPM (referral lab)
Ehrlichia canis ELISA
EIA C-ELISA (send form)
EHV SN (antibody)
Equine Piroplasmosis c-ELISA
Babesia (Theileria) equi
Babesia caballi
EVA SN (antibody)
Heartworm ELISA (canine only)
IBR SN (antibody)
Johne’s ELISA
Leptospirosis MAT (5 serovars)
Lyme Disease ELISA (canine only)
Neospora ELISA (bovine only)
PI3 SN (antibody)
PRRS ELISA
Pseudorabies gB ELISA
Rocky Mountain Spotted Fever IFA
West Nile Virus IgM ELISA
Other (list)
SEROLOGIC PROFILES (all are ANTIBODY tests)
8
Canine (CPV-IFA, CDV-SN)
Cattle Abortion I (Lepto, IBR, BVD, Brucella)
Bovine ELISA panel (BVD, BLV & Johnes)
Cattle Abortion II (Lepto, IBR, BVD, Brucella, Neospora)
Cattle Respiratory (IBR, PI3, BVD, BRSV)
Canine Profile (2 sp. EKrlichia, 2 sp. Anaplasma, Lyme, Heartworm)
Goat/Sheep Abortion I (Lepto, Toxoplasmosis, BT, Brucella)
Horse Abortion (Lepto, EHV I, EVA)
Sheep Abortion II (Lepto, Toxoplasmosis, BT, Brucella, B. ovis)
Swine Abortion (Lepto, Brucella, PRRS, Pseudorabies)
Tick Profile (EKUOLFKLV canis, RMSF, Lyme, Anaplasma)
9
10
11
12
13
14
15
HISTOPATHOLOGY
16
Location:
17
18
19
Size and shape
20
TOXICOLOGY TESTS REQUESTED
Available ICP analysis *
Circle the element(s) requested
under the sample type submitted.
You may select one (1) element or
all. See price list.
Tissue
As
Cd
Cr
Co
Cu
Fe
Pb
Mn
Mo
Se
Zn
Serum
Co
Cu
Mn
Se
Zn
Blood
As
Cd
Cr
Co
Pb
Se
Urine
As
* Interpretation cannot be made on all
elements for all species
Other tests
Aflatoxin (feed only)
Blister beetle ID
Bluegreen algae ID
Cantharidin (urine, stomach content)
Cyanide/prussic acid (forage)
Drug screen-GC/MS
Ethylene glycol-GC/MS
confirmation
Fumonisin (feed only)
Ionophore screen (feed only)
Monensin quantitation
Lead-blood-same day
Nitrate (forage, aq. humor)
Nitrite
Petroleum Hydrocarbons
Rumen pH
Rumen pH, total salts
Strychnine
Sulfate (water only)
Sulfur on feed (referral lab)
Toxic plant/seed ID
Water Quality (pH, Nitrate,
Nitrite, sulfate, total salts,
bluegreen algae)
Are margins submitted?
Yes
No
Unknown
Color, texture, and presence of
capsule:
Growth pattern (expansion, invasion,
pedunculation, etc.):
Duration:
Rate of growth:
Unless written agreements are in place prior to submission to OADDL, all submitted materials plus any biological or chemical material derived from the submission shall
be the property of Oklahoma State University. Any use of such derived material is by permission of Oklahoma State University.
OADDL reserves the right to forward samples to reference subcontractors for tests not currently available at OADDL unless otherwise noted.
G:\SOPS\Receiving\forms\OADDL submittal REC-FM-001.05.doc

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