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: diagcenter@cornell.edu

*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: