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  • www.padls.org

    The Pennsylvania Animal Diagnostic Laboratory System Accession #:

    General Submission Form

    Pennsylvania Veterinary Laboratory Animal Diagnostic Laboratory New Bolton Center Date Received: PA Department of Agriculture The Pennsylvania State University University of Pennsylvania

    2305 North Cameron Street Wiley Lane 382 West Street Road

    Harrisburg, PA 17110 University Park, PA 16802 Kennett Square, PA 19348 Page ______ of ______ (717) 787-8808 (814) 863-0837 (610) 444-5800

    (Lab Use Only)

    PD General Submission Form 01 (December 2014) All Requested Data Must Be Provided.

    PADLS reserves the right to perform tests for any of the diseases regulated by the Pennsylvania Department of Agriculture on any specimen it receives.

    PADLS reserves the right to perform any tests on animals submitted for necropsy that the case coordinator deems necessary for obtaining a diagnosis.

    Your submission of specimens for diagnostic purposes constitutes your acknowledgement that some tests may be performed at other laboratories.

    Bill To: (Lab Use Only) Shipping Method: Vet Practice Drop Off US Mail

    Courier: Ship Date: Owner Opened By: Other:

    Condition Upon Receipt:

    Veterinarian/Submitter: Owner:

    Clinic Premise ID

    Address Address

    City, State, Zip City, State, Zip

    Phone Phone

    Fax Fax

    E-Mail E-Mail

    Preferred Report Distribution Method: Preferred Report Distribution Method:

    US Mail Fax E-Mail No Report US Mail Fax E-Mail No Report

    Animal Information: Test(s) Requested:

    Bovine Caprine Cervine Other:

    Ovine Porcine Equine Program:

    Animal Identification: (Additional space on page 2) SPECIMEN INFORMATION:

    No. Official Animal ID/Name Breed Sex Age Collection Date: _________________

    1 Specimen Type: Pool Specimens (If available)

    2 Blood:

    3 Whole Blood Serum

    4 Feces

    5 Feed

    6 Milk Type: Bulk Tank / Composite / Quarter

    7 Swab: Source ________________________

    8 Tissue: Source ________________________

    9 Fixed Fresh

    10 Other: _________________________

    History / Clinical Signs / Vaccination History / Special Requests:

    SIGNATURE OF VETERINARIAN: _________________________________________

  • www.padls.org

    The Pennsylvania Animal Diagnostic Laboratory System Accession #:

    General Submission Form

    Pennsylvania Veterinary Laboratory Animal Diagnostic Laboratory New Bolton Center Date Received: PA Department of Agriculture The Pennsylvania State University University of Pennsylvania 2305 North Cameron Street Wiley Lane 382 West Street Road Harrisburg, PA 17110 University Park, PA 16802 Kennett Square, PA 19348 Page ______ of ______ (717) 787-8808 (814) 863-0837 (610) 444-5800

    (Lab Use Only)

    PD General Submission Form 01 (December 2014) All Requested Data Must Be Provided

    PADLS reserves the right to perform tests for any of the diseases regulated by the Pennsylvania Department of Agriculture on any specimen it receives.

    PADLS reserves the right to perform any test on animals submitted for necropsy that the Case Coordinator deems necessary for obtaining a diagnosis. Your submission of specimens for diagnostic purposes constitutes your acknowledgement that some tests may be performed at other laboratories.

    Animal Identification: Animal Identification:

    No. Official Animal ID/Name Breed Sex Age No. Official Animal ID/Name Breed Sex Age

    11 46

    12 47

    13 48

    14 49

    15 50

    16 51

    17 52

    18 53

    19 54

    20 55

    21 56

    22 57

    23 58

    24 59

    25 60

    26 61

    27 62

    28 63

    29 64

    30 65

    31 66

    32 67

    33 68

    34 69

    35 70

    36 71

    37 72

    38 73

    39 74

    40 75

    41 76

    42 77

    43 78

    44 79

    45 80

    Vet Practice: Owner: VeterinarianSubmitter: Owner_2: Clinic: Premise ID: Address: Address_2: City State Zip: City State Zip_2: Phone: Phone_2: Fax: Fax_2: EMail_2: US Mail_2: Fax_3: EMail_3: No Report: US Mail_3: Fax_4: EMail_4: No Report_2: Collection Date: Official Animal IDName1: Breed1: Sex1: Age1: Pool Specimens If available: Official Animal IDName2: Breed2: Sex2: Age2: Official Animal IDName3: Breed3: Sex3: Age3: Whole Blood: Serum: Official Animal IDName4: Breed4: Sex4: Age4: Official Animal IDName5: Breed5: Sex5: Age5: Official Animal IDName6: Breed6: Sex6: Age6: Official Animal IDName7: Breed7: Sex7: Age7: Swab Source: Official Animal IDName8: Breed8: Sex8: Age8: Tissue Source: Official Animal IDName9: Breed9: Sex9: Age9: Fixed: Fresh: Official Animal IDName10: Breed10: Sex10: Age10: Other_3: History Clinical Signs Vaccination History Special Requests: Animal Identification: Animal Identification_2: Official Animal IDName11: Breed11: Sex11: Age11: Official Animal IDName46: Breed46: Sex46: Age46: Official Animal IDName12: Breed12: Sex12: Age12: Official Animal IDName47: Breed47: Sex47: Age47: Official Animal IDName13: Breed13: Sex13: Age13: Official Animal IDName48: Breed48: Sex48: Age48: Official Animal IDName14: Breed14: Sex14: Age14: Official Animal IDName49: Breed49: Sex49: Age49: Official Animal IDName15: Breed15: Sex15: Age15: Official Animal IDName50: Breed50: Sex50: Age50: Official Animal IDName16: Breed16: Sex16: Age16: Official Animal IDName51: Breed51: Sex51: Age51: Official Animal IDName17: Breed17: Sex17: Age17: Official Animal IDName52: Breed52: Sex52: Age52: Official Animal IDName18: Breed18: Sex18: Age18: Official Animal IDName53: Breed53: Sex53: Age53: Official Animal IDName19: Breed19: Sex19: Age19: Official Animal IDName54: Breed54: Sex54: Age54: Official Animal IDName20: Breed20: Sex20: Age20: Official Animal IDName55: Breed55: Sex55: Age55: Official Animal IDName21: Breed21: Sex21: Age21: Official Animal IDName56: Breed56: Sex56: Age56: Official Animal IDName22: Breed22: Sex22: Age22: Official Animal IDName57: Breed57: Sex57: Age57: Official Animal IDName23: Breed23: Sex23: Age23: Official Animal IDName58: Breed58: Sex58: Age58: Official Animal IDName24: Breed24: Sex24: Age24: Official Animal IDName59: Breed59: Sex59: Age59: Official Animal IDName25: Breed25: Sex25: Age25: Official Animal IDName60: Breed60: Sex60: Age60: Official Animal IDName26: Breed26: Sex26: Age26: Official Animal IDName61: Breed61: Sex61: Age61: Official Animal IDName27: Breed27: Sex27: Age27: Official Animal IDName62: Breed62: Sex62: Age62: Official Animal IDName28: Breed28: Sex28: Age28: Official Animal IDName63: Breed63: Sex63: Age63: Official Animal IDName29: Breed29: Sex29: Age29: Official Animal IDName64: Breed64: Sex64: Age64: Official Animal IDName30: Breed30: Sex30: Age30: Official Animal IDName65: Breed65: Sex65: Age65: Official Animal IDName31: Breed31: Sex31: Age31: Official Animal IDName66: Breed66: Sex66: Age66: Official Animal IDName32: Breed32: Sex32: Age32: Official Animal IDName67: Breed67: Sex67: Age67: Official Animal IDName33: Breed33: Sex33: Age33: Official Animal IDName68: Breed68: Sex68: Age68: Official Animal IDName34: Breed34: Sex34: Age34: Official Animal IDName69: Breed69: Sex69: Age69: Official Animal IDName35: Breed35: Sex35: Age35: Official Animal IDName70: Breed70: Sex70: Age70: Official Animal IDName36: Breed36: Sex36: Age36: Official Animal IDName71: Breed71: Sex71: Age71: Official Animal IDName37: Breed37: Sex37: Age37: Official Animal IDName72: Breed72: Sex72: Age72: Official Animal IDName38: Breed38: Sex38: Age38: Official Animal IDName73: Breed73: Sex73: Age73: Official Animal IDName39: Breed39: Sex39: Age39: Official Animal IDName74: Breed74: Sex74: Age74: Official Animal IDName40: Breed40: Sex40: Age40: Official Animal IDName75: Breed75: Sex75: Age75: Official Animal IDName41: Breed41: Sex41: Age41: Official Animal IDName76: Breed76: Sex76: Age76: Official Animal IDName42: Breed42: Sex42: Age42: Official Animal IDName77: Breed77: Sex77: Age77: Official Animal IDName43: Breed43: Sex43: Age43: Official Animal IDName78: Breed78: Sex78: Age78: Official Animal IDName44: Breed44: Sex44: Age44: Official Animal IDName79: Breed79: Sex79: Age79: Official Animal IDName45: Breed45: Sex45: Age45: Official Animal IDName80: Breed80: Sex80: Age80: Tests Requested Program: Group1: 6EMail: OtherAnimal: Blood: Feces: Milk: Swab: Tissue: Feed: Other: Bill To Other:

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