_______

Your Internal Case / Reference No. **____________________________

SPECIES

Phone No. (_______)___________________________________

County_______________________Town____________________

AGE / DOBBREEDNAME / IDENTIFIER NO. SEX

DATE TAKEN SPECIMEN TYPE TESTS

______________

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

Check here if additional history is attached.

LAB USE ONLY

________________________AHDC Accession No. / Date _________

Address______________________________________________

O wner_______________________________________________

Enter Your Cornell AHDC Acct. No.

City, State, Zip_________________________________________

Animal Identification and Submitted Tissue:

NYS Premises ID_______________________________________

FISH (Simpson Lab)

FISH KIT Submission FormAnimal Health Diagnostic CenterCollege of Veterinary Medicine, Cornell University

In Partnership with the NYS Dept. of Ag & Markets

Cost of Testing: The cost of testing is $190.00 for the first fixedtissue and $50 for each additional tissue submitted at the same time. There is also a $50 fee for each additional probe requested. Please submit 5 unstained sections/per tissue on separate charged glass slides. If formalin fixed tissue or paraffin embedded blocks are submitted, an additional $30 fee per tissue block will be assessed and an additional 5-10 business days will be added to the turnaround time.

Test Information: Results are examined and interpreted by the Simpson Lab group of Cornell University’s Veterinary Clinical Science Department, which is independent of the AHDC. Turnaround time is dependent upon Dr. Simpson's availability. While typical turnaround time is 5-10 business days, it can sometimes take as long as 15 business days if Dr. Simpson is unavailable. We encourage clients to call the lab if they are concerned about turnaround time or other information at 607-253-3567.

PLEASE COMPLETE ALL FIELDS, PRINT LEGIBLY, AND ENTER ONLY ONE OWNER PER FORM

PLEASE NOTE: SAMPLES SUBMITTED FOR TESTING BECOME THE PROPERTY OF THE ANIMAL HEALTH DIAGNOSTIC CENTER AND

MAY BE TESTED AS PART OF STATE/FEDERAL SURVEILLANCE PROGRAMS

US Postal Service Address: FedEx/UPS Service PO Box 5786 Address: 240 Farrier Rd. Ithaca, NY 14852-5786 Ithaca, NY 14853

AHDC Contacts Phone: 607-253-3900 Fax: 607-253-3943 Web: www.vet.cornell.edu/ahdc Email: diagcenter@cornell.edu

Type of tissue(s) submitted:

Slide(s) Submitted:

Diagnosis/Treatment:

Histology Report Included?

Submitting Veterinarian *____________________________________________

Clinic Name___________________________________________

Address______________________________________________

City, State, Zip_________________________________________

Phone No. (____)______________ Fax No. (____)_______________

EMAIL REQUIRED:

Submitting Vet's Signature:________________________________

Brief Clinical History:

Please check here to authorize sharing of HISTO and Panel 2 results with the Simpson Lab. Account 17540

Please list any previous accessions.

5 Unstained slides

Parraffin Block

Tissue (wet)

Yes No

FISH Kit Aerobic, Campylobacter

and Salmonella Cultures (AHDC)

AHDC USE ONLY FEDEX MAIL DATE REC'D:________________________ FROZEN DRY ICEOPENED BY: FEDEX-GRND PRI MAIL RM TEMP COLD PACK

TIME REC'D:________________________

UPS-GRND EXP MAIL COOL NONE_________________ UPS-ND OTHER:___________DATE SHIPPED:_____________________ COLD COMMENT:_____________

*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).

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HISTO (AHDC) Comments: