Billing Party: Owner

1 FOR LAB USE ONLY. Section(s): C B M N P S T V. Case Coordinator: Deliveries: 1490 Bull Lea Rd., Lexington, KY 40511 Carrier: M B D U F O V Other US Mail: PO Box 14125, Lexington, KY 40512-4125. Phone: (859) 257-8283 Fax: (859) 255-1624 Rec'd By / Ship Date: Comments: Billing Party: Veterinarian Owner Other: Owner : Veterinarian: Name: Clinic: Business: Address: Address: City: State: Zip: City: State: Zip: Phone: Fax: Phone: Fax: Email: Email: If additional copies of report are needed, please include E-mails or fax numbers here: General Information (Please provide as much information as possible): Field Necropsy (Submitted samples RABIES SUSPECT Diagnostic Necropsy Cremation Neurologic (Spinal Cord Removal).)

2 Tested at discretion of Pathologist). RABIES ONLY Regulatory Surveillance Sale / Prepurchase Export Sample: (Rabies Form Required). (Country of Destination). Location of Animal (county, state, premise ID). Animal ID / Name* Species Breed Gender Age (w/ units**) Weight Color *Multiple submissions from same premises require the use of the Accession Continuation Form (available at ) **Hrs, days, wks, mos, or yrs History (Attach additional history if provided space is inadequate). Duration of Illness: Euthanized Vaccination Status: (Method of Euthanasia ).

3 Date of Death: # Sick Animals # Animals in Group Insured Related Accession: (Insurance Company) # Dead Animals # Animals on Farm Please describe: 1. Clinical Signs 2. Vaccinations 3. Treatments 4. Nutrition 5. Environment 6. Other Clinical Diagnosis(es): Submitted Specimen Information (Please check all that apply): SPECIMEN COLLECTION DATE: Tissue / Biopsy Information Carcass Urine Feces Feed / Forage Tissue Fresh Information: Fixed (List Fixative): Fetus Placenta Milk Neoplasm Size: Blood (Whole blood, Serum or Plasma) (LxWxD in cm).

4 Specify stopper color as submitted: Shape: Purple Red (Gel Separator tubes Not Recommended). Other: Attachment: Fluid (List Type): Tissue Involved: Dorsal Swab (List Source / Site): Gross Appearance: Other: Consistency: The information and animal specimens submitted to the University of Kentucky Veterinary Diagnostic Laboratory are done so under the protection of the Color: Veterinarian-Client-Patient relationship, as codified in KRS , and are confidential. Privileged information regarding patients will not be released without Duration: the Owner 's consent, unless disclosure is required by law.

5 Specimens submitted will Development become the property of UKVDL and will not leave the laboratory except for Rate: contract disposal or pre-arranged cremation. Ventral For Cytology Information, complete section on back of form. Signature of Submitter: Date: UKVDL Form 001 Version 6 08 / 2020 Authorized by QAM Page 1 of 2. Test Offerings (Please check all that apply): Only the most frequently requested tests are listed below. For a complete list of test offerings, specimen and sample handling conditions, please visit our website ( ) or call 859-257-8283 for further assistance.

6 SPECIMEN REQUIREMENT KEY Serology Virology TRANS Gel Separator tubes should not be submitted. Virus Isolation (SW, T, TTW, PT). Cerebro- Avian F FECES CSF TTW TRACH Contact lab for full list of specimen options Spinal Fluid Avian Influenza (S) Bovine WASH. Mycoplasma (Synoviae/Gallisepticum) (S) BVDV Antigen ELISA (for PI). OCULAR. OF SW SWAB U URINE Salmonella pullorum (S) Ear Notch Serum FLUID. Bovine BVDV-VN 1&2 (S). PURPLE TOP. S SERUM T TISSUE PT Anaplasma marginale (S) Infectious Bovine Rhinotracheitis (IBR)-VN (S). TUBE.

7 10ml PURPLE. Bluetongue Virus (S) Respiratory Syncytial Virus (BRSV)-VN (S). PT-10ml Bovine Leukemia Virus (S) Equine TOP TUBE. Bovine Pregnancy Test (S) Equine Herpes Virus-1 (EHV-1)-VN (S). Blood Collection Tubes: Red Top Tubes = Serum Brucella abortus (S) Equine Viral Arteritis (EVA)-VN (S). Lavender / Purple Top Tubes = Whole Blood Leptospira (MAT) Screen (S) Check if vaccinated for EVA. Date: Bacteriology Neospora caninum (S) Equine Influenza-HI (A1 & A2) (S). Johne's (Mycobacterium paratuberculosis) (S) Potomac Horse Fever-IFA (S).

8 Aerobic Culture Equine Vesicular Stomatitis-VN** (NJ & IN) (S). Salmonella Screen Brucellosis (S) **Dilution Rate: Strept. equi. Screen Equine Tick Panel (S) West Nile-IgM Capture ELISA (S). Anaerobic Culture Lyme Disease (S). C. Perf. Screen EPM-IFAT (S, CSF). Leptospira MAT (specify below): (S) Canine Fungal / Yeast Culture 2 serovar 5 serovar Eye Panel (S). Mastitis Culture (susceptibility by request) Distemper virus FA (PT, U, Conjunctival Smear). Piroplasmosis (specify below): (S). Mycoplasma Culture* B. caballi T. equi Other: (S).

9 *No susceptibility routinely offered. Canine Molecular (PCR). Other: B. burgdorferi (Lyme Disease) (S,PT). Bluetongue PCR (PT-10ml, SW, TTW). Brucella canis (B. canis) (S). Clinical Pathology BVDV PCR (PT-10ml). Canine Heartworm (S). (S) Ear Notch Serum Tissue Canine Pregnancy Bile Acids - Pre and Post (S) (S) Canine Influenza PCR (SW, TTW). Fungal Tests (specify below): CBC (PT) (S). Epizootic Hemorrhagic Disease (PT-10ml, SW, TTW). Blastomyces dermatitidis Equine Adenovirus PCR. CBC - No Differential (TTW, SW, T). (PT) Histoplasma capsulatum (S).

10 Chemistry Panel - Species Specific (S) EPM (Sarcocystis neurona) PCR (CSF, T). Leptospira (MAT) Screen (S). Equine Herpes Virus PCR (TTW, SW, PT-10ml). Chemistry Panel - Renal or Hepatic (S) Tick panel (canine) (S). Fibrinogen Specify Type Below: (PT + S) Feline Phenobarbital (S). Type 1 Type 2 Type 3 Type 4 Type 5. Feline Immunodeficiency Virus (FIV) (S). Fecal Cryptosporidia (F) Equine Influenza PCR (TTW, SW). Feline Infectious Peritonitis (FIP) Virus (S,PT). Fecal Parasite Exam (Qualitative) (F) Equine Viral Arteritis PCR (SW, PT-10ml, T).