BOVINE SUBMISSION FORM - Prairie Diagnostic Services Submission Form 2016.pdf · ** Fill out page 3...
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1 BOVINE SUBMISSION FORM Invoice to Owner/Farm Name: Clinic: Address: Animal Location/Premise ID: Postal Code: Phone: Animal ID: Veterinarian: Fax: Print name Species: BOVINE Breed: Email: Copy to: Sex: Male MN Female Age: ________________ STAT (fees apply) Rabies Suspect Legal Case Insurance Case Date Collected: _________________ Reason For Submission Diagnostic Research Surveillance Routine Monitoring HISTORY: (including vaccination history, treatments etc) Special Project Name (if applicable): ________________ Previous Submission #: _________________ Submitters Signature: __________________________ Samples Sent Received office use only On cells EDTA Serum Fluid Slides Milk Urine Feces Swab Fixed Tissues Fresh Tissues Paraffin Block Whole Animal Other _______ _____________ Herd Size: _________________________ No. sick:__________________________ No. dead:__________________________ New disease, duration: _______________ Ongoing disease, duration:____________ __________________________________ Non disease: _______________________ __________________________________ Chemistry Panels Standard Kidney Presurgical Liver Single Chemistry: ________________ Other __________________________ Hematology CBC Blood smear Evaluation Other _________________________ Endocrine BioPRYN Estradiol Progesterone Testosterone Other __________________________ Urine Freeflow Cystocentesis Catheterized Unknown Urinalysis Culture Other __________________________ Cytology Fluid(s) Smear(s) Other __________________________ ** see page 3 for diagrams and list of sites Referred out Test Leptospirosis Other __________________________ ___________________________ ___________________________ Bacteriology Specimen & Site: _________________ Routine Culture & Sensitivity Campylobacter sp. Salmonella sp. Anthrax Clostridium FA E.coli virotyping by PCR Fungal culture Johne’s Stain Stain & Culture Mycoplasma sp. Other ______________________ Parasitology Routine Flotation Fecal Egg Count Giardia & Cryptosporidium combo Other ______________________ Immunology IHC for infectious agent ______________________________ BVD skin biopsy Immunoglobulin Quantification Other ______________________ PCR BVD Bovine Papilloma Campylobacter fetus Chlamydophila sp. Clostridium perfringens E.coli virotyping Johne’s Mycobacterium sp. Mycobacterium bovis Mycoplasma bovis Tritrichomonas foetus Ureaplasma sp. Other ________________________ Serology Brucella (BPAT) - Must be accompanied by CFIA forms BVD-1 BVD-2 BRSV IBR PI3 Coronavirus Bovine Respiratory panel Histophilus somni Johne’s Mannheimia haemolytica Neospora Leukosis Toxicology Mineral Panel: #1 #2 #3 #4 Single element _______________________________ Nitrate Vitamin A Vitamin E Vitamin A and E Vitamin D Virology Corona/Rotavirus fecal FAT Fluorescent Antibody Test BRSV BVD IBR PI3 Coronavirus rotavirus Virus isolation BVH-2 BVD IBR PI3 EM for _______________________ Pathology/Necropsy **Dermatopathology **Surgical Biopsy *Complete Necropsy *Histology *Fill out page 2 – Necropsy Form* ** Fill out page 3 – Surgical biopsy/dermatopathology form ** NATIONAL SURVEILLANCE Please complete this section. Production Stage Fetus Neonate Nursing Weaned Feeder Replacement Heifer Backgrounder Adult Primary Systems Affected Abortion/Stillbirth Cardiovascular Gastrointestinal Integument (skin) Mammary Musculoskeletal Neurological Reproductive Respiratory Sudden/Unexplained Death Unthriftiness/Anorexia/Poor Production Urinary Whole body/Multisystem Non disease Other 12/02/2014 Prairie Diagnostic Services Inc. www.pdsinc.ca 52 Campus Drive Saskatoon, SK, S7N 5B4 TEL: (306) 966-7316 FAX: (306) 966-2488 Date/Time (RECEIVED) PDS Lab # ____________________
Transcript of BOVINE SUBMISSION FORM - Prairie Diagnostic Services Submission Form 2016.pdf · ** Fill out page 3...
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BOVINE SUBMISSION FORM
Invoice to Owner/Farm Name: Clinic:
Address: Animal Location/Premise ID:
Postal Code: Phone: Animal ID: Veterinarian: Fax: Print name
Species: BOVINE Breed: Email: Copy to: Sex: Male MN Female Age: ________________
STAT (fees apply) Rabies Suspect Legal Case Insurance Case Date Collected: _________________ Reason For Submission
Diagnostic Research Surveillance Routine Monitoring
HISTORY: (including vaccination history, treatments etc) Special Project Name (if applicable): ________________
Previous Submission #: _________________ Submitters Signature: __________________________
Samples Sent Received office use only
On cells EDTA Serum Fluid Slides Milk Urine Feces Swab Fixed Tissues Fresh Tissues Paraffin Block Whole Animal Other _______ _____________
Herd Size: _________________________ No. sick:__________________________ No. dead:__________________________ New disease, duration: _______________ Ongoing disease, duration:____________ __________________________________ Non disease: _______________________ __________________________________
Chemistry Panels
Standard Kidney Presurgical Liver Single Chemistry: ________________ Other __________________________
Hematology
CBC Blood smear Evaluation Other _________________________
Endocrine
BioPRYN Estradiol Progesterone Testosterone Other __________________________
Urine Freeflow Cystocentesis Catheterized Unknown
Urinalysis Culture Other __________________________
Cytology
Fluid(s) Smear(s) Other __________________________
** see page 3 for diagrams and list of sites Referred out Test
Leptospirosis Other __________________________
___________________________ ___________________________
Bacteriology Specimen & Site: _________________
Routine Culture & Sensitivity Campylobacter sp. Salmonella sp. Anthrax Clostridium FA E.coli virotyping by PCR Fungal culture Johne’s Stain Stain & Culture Mycoplasma sp. Other ______________________
Parasitology Routine Flotation Fecal Egg Count Giardia & Cryptosporidium combo Other ______________________
Immunology IHC for infectious agent
______________________________ BVD skin biopsy Immunoglobulin Quantification Other ______________________
PCR BVD Bovine Papilloma Campylobacter fetus Chlamydophila sp. Clostridium perfringens E.coli virotyping Johne’s Mycobacterium sp. Mycobacterium bovis Mycoplasma bovis Tritrichomonas foetus Ureaplasma sp. Other ________________________
Serology Brucella (BPAT) - Must be
accompanied by CFIA forms BVD-1 BVD-2 BRSV IBR PI3 Coronavirus Bovine Respiratory panel Histophilus somni Johne’s Mannheimia haemolytica Neospora Leukosis
Toxicology Mineral Panel:
#1 #2 #3 #4 Single element
_______________________________ Nitrate Vitamin A Vitamin E Vitamin A and E Vitamin D
Virology Corona/Rotavirus fecal FAT Fluorescent Antibody Test
BRSV BVD IBR PI3 Coronavirus rotavirus
Virus isolation BVH-2 BVD IBR PI3
EM for _______________________ Pathology/Necropsy
**Dermatopathology **Surgical Biopsy *Complete Necropsy *Histology
*Fill out page 2 – Necropsy Form* ** Fill out page 3 – Surgical biopsy/dermatopathology form **
NATIONAL SURVEILLANCE Please complete this section.
Production Stage
Fetus Neonate Nursing Weaned Feeder Replacement Heifer Backgrounder Adult
Primary Systems Affected Abortion/Stillbirth Cardiovascular Gastrointestinal Integument (skin) Mammary Musculoskeletal Neurological Reproductive Respiratory Sudden/Unexplained Death Unthriftiness/Anorexia/Poor
Production Urinary Whole body/Multisystem Non disease Other
12/02/2014
Prairie Diagnostic Services Inc. www.pdsinc.ca
52 Campus Drive Saskatoon, SK, S7N 5B4 TEL: (306) 966-7316 FAX: (306) 966-2488
Date/Time (RECEIVED) PDS Lab # ____________________
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NECROPSY SUBMISSION
(Please fill out page 1 and submit along with this form.) Clinic: Owner/Farm Name:
Signs of sickness: _________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Date of death: _________________________ Euthanasia: method/route: _________________________________________________ Housing and management (pasture, feedlot, etc) __________________________________________________________________________ Source of recent additions ______________________________________________ When: _____________________________________ Ration fed: ______________________________________________________________ Recent change to ration? __________________ Supplements, minerals or vitamins: _________________________________________ Source of water: __________________________ If abortion: Age of dam: ____________ Estimated age of fetus: _____________ Breeding: (AI/Natural) ___________ Number aborted: __________ Fixed tissues submitted: ____________________________________________________________________________________________ Fresh tissues submitted: _____________________________________________________________________________________________ Lab test (s) requested: 1)______________________ 2) ________________________ 3) __________________________ 4) _________________________ Gross Necropsy Notes:
12/02/2014
Prairie Diagnostic Services Inc. www.pdsinc.ca
52 Campus Drive Saskatoon, SK, S7N 5B4 TEL: (306) 966-7316 FAX: (306) 966-2488
Date/Time (RECEIVED) PDS Lab # ____________________
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SURGICAL BIOPSY/DERMATOPATHOLOGY SUBMISSION (Please fill out Page 1 and submit along with this form.)
Clinic: Owner Name:
Surgical Biopsy On diagram below shade areas and mark “X” as biopsy sitesSamples submitted: # of formalized tissue biopsies _______ Description ___________________________________________________________
# of fresh tissues biopsies __________ Description ___________________________________________________________
# of cytology specimens ____________ List sites: 1) _________________________________________________________ 2) _________________________________________________________3) _________________________________________________________4) _________________________________________________________
Dermatopathology Submissions
Circle lesion type Primary
bulla macule nodule papule patch plaque tumor vesicle wheal
Secondary
abscess alopecia callus collarette comedone crust cyst erythema erosion
excoriation fissure hyperkeratosis hyperpigmentation hypopigmentation scale scar ulcer
On diagram below shade areas and mark “X” as biopsy sites
Duration of problem ________________________________ Animal is pruritic YES _____ NO _____ Don’t know _____
Pertinent History ___________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Other test results ____________________________________________________________________________________
Treatments _________________________________________________________________________________________
Response _________________________________________________________________________________________
Tentative Diagnosis _________________________________________________________________________________
Immunohistochemistry: YES _____ NO ____ Call First _____
12/02/2014
Prairie Diagnostic Services Inc. www.pdsinc.ca
52 Campus Drive Saskatoon, SK, S7N 5B4 TEL: (306) 966-7316 FAX: (306) 966-2488
Date/Time (RECEIVED)
PDS Lab # ____________________
