Transcription of Animal Health Diagnostic Center
1 General Submission Form LAB USE ONLY. Animal Health Diagnostic Center _____. College of Veterinary Medicine, Cornell University AHDC Accession No. / Date In Partnership with the NYS Dept. of Ag & Markets AHDC Contacts PLEASE NOTE: SAMPLES SUBMITTED FOR. Phone: 607-253-3900 TESTING BECOME THE PROPERTY OF THE. US Postal Service Address: fedex /UPS Service Fax: 607-253-3943 Animal Health Diagnostic Center AND. PO Box 5786 Address: 240 Farrier Rd. Web: MAY BE TESTED AS PART OF STATE/FEDERAL. Ithaca, NY 14852-5786 Ithaca, NY 14853 Email: SURVEILLANCE PROGRAMS. PLEASE COMPLETE ALL FIELDS, PRINT LEGIBLY, AND ENTER ONLY ONE OWNER PER FORM. Enter Your Cornell AHDC Acct. Your Internal Case / Reference No. **_____. Submitting Veterinarian *_____. Owner_____. Clinic Name_____. Address_____. Address_____. City, State, Zip_____.
2 City, State, Zip_____. Phone No. (_____)_____. Phone No. (____)_____ Fax No. (____)_____. E-Mail Address: _____ County_____Town_____. Submitting Vet's Signature:_____ NYS Premises ID_____. Check if appropriate: p Regulatory p Export Country of Destination_____ Shipper/Exporter_____. HISTORY/CLINICAL INFORMATION: Please check all that apply: p Normal p Hematological/Hemorrhage p Dermatological p Fever p Neurological p Hepatic p Gastrointestinal/Diarrhea p Abortion/Repro Failure p Endocrine p Sudden Death p Urinary/Urogenital p Musculoskeletal/Lameness p Edema p Ocular p Neoplasia p Chronic Weight Loss p Production/Performance decline p Respiratory p Anorexia p Cardiac p Erosion/Vesicular p Other_____. Clinical / Differential Diagnosis:_____. Has related material been submitted previously for this Animal (s)/herd: p Y p N Accession Date of onset of Herd illness:_____ In animals submitted:_____ Herd size:_____ No.
3 Dead:_____ No. affected:_____. Additional Info / History: p Check here if history is continued on back of this page, or if add'l history is attached. Animal IDENTIFICATION INDICATE SPECIMEN TYPE TEST(S) REQUESTED. SEX CODES: M=Male, MR=Mare (equine only), MC=Castrated Male, F=Female, SF=Spayed Female DATE. (AND ANATOMIC LOCATION - if (per Animal ). AGE CODES: Y=Years, M=Months, W=Weeks, D=Days; DOB=Date of Birth appropriate) TAKEN. ENTER FULL NAME OF TEST. NO. NAME / IDENTIFIER NO. SPECIES BREED SEX AGE / DOB. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Comments: p check if continuation page included AHDC USE ONLY p fedex p MAIL DATE REC'D:_____ p FROZEN p DRY ICE. OPENED BY: p fedex -GRND p PRI MAIL p RM TEMP p COLD PACK. TIME REC'D:_____. p UPS-GRND p EXP MAIL p COOL p NONE. _____ p UPS-ND p OTHER:_____DATE SHIPPED:_____.
4 _____ p COLD p COMMENT:_____. *The submitting veterinarian is responsible for the requested tests, fees associated with this submission, and to notify the owner of test results. Page ____ of ____. **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). ORG-WEB-027-V01.
