ahdc express form - cornell university college of ...€¦ · email: [email protected] *the...
TRANSCRIPT
O wner _____________________________________________
City, State____________________________________________
For all culture requests, please indi cate sample s ource:
If Urine ____Cysto or ____ Other: ___________________ Susceptibility ___Yes ___No (Require d) Has animal received antimicrobials w/in last 72 hrs? ___Yes ___No
FedEx/UPS Service Address: 240 Farrier Rd. Ithaca, NY 14853
' Most Requested Equine Spec. Most Requested Small Animal Most Requested Bacteriology I
Other Tests Not Listed
Most Requested Other SW
Brief history, additional comments or previous accession number:
AHDC Express Form
College of Veterinary Medicine, Cornell University In P artnership with th e N YS D ept. of A g & M arkets
DRY ICE COLD PACK
COOL NONE p UPS-ND p
MAIL PRI MAIL EXP MAIL OTHER:__________ p COLD p COMMENT:_____________
Page 1 of 1 ORG-WEB-097-V02
UPS-GRND DA TE SHIPPED:_____________________
LAB USE ONLY
__________________________________AHDC Accession No. / Date
PLEASE NOTE: SAMPLES SUBMITTED FOR TESTING BECOME THE PROPERTY OF THE ANIMAL HEALTH DIAGNOSTIC CENTER AND
MAY BE TESTED AS PART OF STATE/FEDERA L SURVEILLANCE PROGRAMS
Animal Health Diagnostic Center
US Postal Service Address: PO Box 5786 Ithaca, NY 14852-5786
PLEASE COMPLETE ALL FIELDS, PRINT LEGIBLY, AND ENTER ONLY ONE OWNER PER FORM
AHDC Contacts Phone: 607-253-3900 Fax: 607-253-3943 Web: ahdc.vet.cornell.edu Email: [email protected]
*The submitting veterinarian is responsible for the requested tests, fees associated with this submission, and to notify the owner of test results.
**If your Internal Reference No. is entered on this form, it will be used to identify this case on the test result form and on the billing statement (max. 17 character field).
FROZEN p FEDEX-GRND p p RM TEMP p
p p p p
Your Internal Case / Reference No. **____________________________
AHDC USE ONLY OPENED BY:
FEDEX
Enter Your Cornell AHDC Acct. No.______________________________
Submitting Veterinarian *_____________________________________________________
Clinic Name___________________________________________
Address ______________________________________________
City, State, Zip ________________________________________
Phone No. (____)______________ Fax No. (____)_____________
2
SPECIES AGE / DOB BREEDNO. NAME / IDENTIFIER NO.
3
SEX
1
ANIMAL IDENTIFICATION
SEX CODES: M=Male, MR=Mare (equine only), MC=Castrated Male, F=Female, SF=Spayed Female AGE CODES: Y=Years, M=Months, W=Weeks, D=Days; DOB=Date of Birth
DATE TAKEN
Spec. Spec.
P EDTA Plasma (Purple Top) SL Slide
SW Swab
WB EDTA Whole Blood (Purple Top T Tissue
V Variable U Urine
See web for complete list of acceptable specimens
Preferred specimen key below. Please indicate number of specimens submitted.
Please label all containers clearly!
F Feces
CSF Cerebral Spinal Fluid FL Fluid
S Serum (Red Top)
SWTM Swab in Transport Media
HEPP Heparinized Plasma (Green Top)
CITP Citrated Plasma (Blue Top)
p p p p
ACTH Baseline (ACTHEQ) P Anti-Mullerian Hormone ELISA (AMH) S
ACTH + Insulin (ACTHIN) P Canine Brucella Slide AGID II (CANBR) S
ACTH + Insulin + Leptin (ACINLP) P Canine Respiratory Panel (CRPN L) SW ACTH Pre TRH Response (ACTHPRETRH) P Canine Va ccine Pane l 1 (CDVSN/CPVHI) S
ACTH Post TRH 10min (ACTHPOSTTRH1)
P Canine Vaccine Pane l 2 (CVP1+CAVSN) S
Anaplasma phagocytophilum PCR [Ehrlichia equi] (EHRE)
WB Chemistry Panel, Small Animal (SA P) S Aerobic Bacterial Culture (A ER) T, SWTM, or FL
Coronavirus, Alpha PCR (ACOR) V Anaerobic Bacteri al Culture (ANAER) Please submit swabs in unexpired, anaerobic transport media
T, SWTM, or FL Chemistry Panel, Large Animal (LA P) S Cortisol baseline (CORT) S
Coronavirus, Beta PCR (BCOR) F D-dimer Quantitative (DDIQ) CITP Fungal Culture (FUNGCM) T, SWTM, or FL
D-dimer Quantitative (DDIQ) CITP Fecal Flotation (F LOAT) F Leptospira MAT 5 Serovars (LEPTO) S
Estrone Sulfate (E1S) S Feline Respiratory Panel (FRPNL) SW Leptospira MAT 7 Serovars (LEPTOPNL) SFecal Flotation (FLOAT) F Hemogram, Small Animal (SA CBC)
Mycoplasma Culture (MYCOPL) T, SWTM, or FL Glucose, Blood (GLU) P or S -
Lyme Disease Multiplex (CLM) S
Salmonella Culture (SALM) F, T, SWTM, or FL
Hemogram, Large Animal (LA CBC) WB + 2SL Protein C (PROTC) CITP
Strep equi Culture (SEQUCUL) T, SWTM, or FL Herpesvirus PCR Panel (EHVPNL) WB + SW T4 (Throxine) Baseline (T4) S
Ureaplasma Culture (UREAPL) T, SWTM, or FL Insulin Baseline (INSEQ) Testosterone Baseline (TE)
Urine Culture (URCUL) U or SWTM Lyme Disease Multiplex (EQLM) S Thyroid Panel [FT4/ T4/ T3/ TSH/ TGA] (THYPIK9) S
Pre-Purchase Drug Screen (PPDS) HEPP von Willebrand factor (VWF) CITP
Progesterone baseline (PRE) Spec. Respiratory Pa nel (ERPNL)
Cytology Smear Exam (C YSMR) SL Streptococcus PCR [Strep Equi] (SEQUPCR) SW
Parasite Identification (PID) V WB
T4 (Throxine) Immuli te (T4I) S
Testosterone Baseline (TE)
Thyroid Panel [FT4D, T4, T3] (THYPALLI) S
S
P or S
P or S
P or S
WB + 2SL
P or S
Selenium (SEL)
Vitamin E (NDIK)
Click here to print:
DATE REC'D:_____________________
TIME REC'D:________________________
Ovarian Remnant Syndrome Panel (OVRCF) S
E-mail Address: