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2009 submission form updated.pub (read-only)

TDA Laboratories, LLC
Mailing/Physical Address: Phone:
Fax: 970.351.8134
Submission Form
Note: This is a 2-page form. Please fill out both pages completely and legibly.
Owner/Contact Name: ___________________________________
Clinic/Veterinarian: ______________________________________
Business: __________________________________________ Contact: ________________________________________________ Address: ______________________________________________ Address: _______________________________________________ City: ________________________ State: ____ Zip: __________ City: _________________________ State: ____ Zip: ___________ Phone: ____________________________________ Phone: ______________________________________ Fax: ____________________________________ Fax: ______________________________________ Email: ________________________________________________ Email: _________________________________________________
Person to be Billed: □
Owner/Producer □ Veterinarian Report Results to: □ Owner/Producer □ Veterinarian

Send Results by : □
Fax □ Phone □ Email Mail
Species: □ Bovine
□ Canine □ Feline □ Equine □ Camelid □ Other (specify) ____________________________ Specimen(s) Submitted:
□ Whole Blood □ Serum □ Milk □ Urine □ Feces □ Semen □ Fetus □ Tissue (specify)
□ Culture plate/isolate □ Feed □ Water □ Swab (specify) □ Other (specify) _________________________________
For multiple animal submissions, use ‘Multiple Animal Identification Sheet’
Animal Identification

Sex Age Collection Date


History (include clinical signs, differential diagnoses, antibiotic use, vaccine history, duration, number of animals affected, etc.) If
more space is needed, please attach an additional page.

For Lab Use Only
COOLANT RECORD Frozen Dry Ice Cold Pack None Comment ____________________________________________________________
SAMPLE CONDITION Good Broken Leaked Warm Frozen Other ________________________________________
SHIPPING INFORMATION Mail FedEx Exp Mail UPS Courier Hand Delivered
Contact Name ____________________________________________________________

□ Blood culture

Chemistry Panels
Comprehensive Diagnostic □ T4/Cholesterol □ Pre-Anesthetic
□ Critical Care □ Equine Profile Plus ** □ Mammalian Liver ** □ Large Animal ** Tests will require an additional 1 –2 days
CBC/ Biochem Comprehensive

Urine Culture: Method of Collection: □ Cysto □ Catheter □ Free catch
□ Fecal Complete (includes: Float, Cytology and Giardia)
Urinalysis (includes: Specific Gravity, Dip Stick and Sediment)
Aerobic ID and Susceptibility
Anaerobic ID and Susceptibility

Heartworm □ Feline □ Canine (includes: Heartworm , E. Canis & Lyme Disease )
Heartworm, E. Canis and Lyme Disease
□ Heartworm, E. Canis, Lyme Disease and Anaplasmosis
SNAP Giardia
□ SNAP Parvo

□ Culture □ Bacteria & Mycoplasma (All bacteria identified)
□ Tank Sample □ Contagious only (Staph aureus, Strep ag., Mycoplasma) □ Milk Quality □ SCC □ PC □ PI □ LPC □ Coliform Count (If more than one tests required, circle all.)
Antibiotic Susceptibility **Other antibiotics available upon request
Small Animal **(includes: Amikacin, Amoxicillin/Clavamox, Cephalothin, Cefazolin, Doxycycline,
Enrofloxacin, Erythromycin and Sulfasoxazole)
Food Animal **(includes: Ampicillin, Ceftiofur, Enrofloxacin, Florfenicol, Penicillin, Sulfa/Trimethoprim,

Residue Testing: □ Milk/Urine Residue Testing (Test used for potential slaughter animal also.)
□ Antibiotic residue test: □ Penicillin □ Other: ________________________________________
□ Johne’s :

□ BioPryn Pregnancy Test (serum)

□ Mycoplasma—PCR
Ear notch/serum—Elisa
Milk—PCR □Milk—Elisa

□ Tissue Culture
(Type/location) _________________________________________
Method of Collection ____________________________________
□ Bedding Culture

□ Bedding Culture with Myco

□ Abortion Screens
(Elisa) (IBR, BVDV and BHV4) □ Respiratory Screens (Elisa) (IBR, BRSV, PI3, & Andenovirus 3)

□ Anaplasmosis (Elisa) □ Blue Tongue (Elisa) □ Neospora (Elisa)

□ Bovine Leukemia Virus (Elisa) □ Colostrum IgG □ Trichomonas

□ Stains:

□ Acid Fast (Cryptosporidium) □ Wright-Geisma □ Gram □ Dif Quick
□ pH Analysis
(Type) □ Water Analysis □ Ear Cytology

Source: http://www.dairymd.com/2009submissionform.pdf

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