PINK EYE DIAGNOSTICS SUBMISSION FORM · PINK EYE DIAGNOSTICS SUBMISSION FORM MADISON 445 Easterday...

For Laboratory Use Only

Frozen Chilled Warm

Animal / Specimen ID Species Breed Sex Age Specimen type Test(s) requested

LABEL

OWNER*__________________________________ Farm Name_____________________________________ Address*________________________________________ City*___________________________________________ State*/Zip*______________________________________ Premise ID______________________________________ ________________________________________________

VETERINARIAN* _____________________________ License No.* __________________________________________ Clinic _______________________________________________ Clinic Acct. No. _______________________________________ Address* _____________________________________________ City* ________________________________________________ State* /Zip* ___________________________________________ Clinic Premise ID ______________________________________ E-MAIL* ____________________________________________

Phone* ____________________ FAX* __________________

Submitting Veterinarian’s Signature*_________________________________________________________________

(Signature indicates that specimen(s) were collected by or under the supervision of the signing veterinarian.)

SPECIMEN INFORMATION

www.wvdl.wisc.edu

E-mail: submissions@wvdl.wisc.edu

PINK EYE DIAGNOSTICS SUBMISSION FORMMADISON445 Easterday Lane, Madison, WI 53706 PH: (800) 608-8387 FAX: (608) 504-2594

BARRON1521 E. Guy Ave., P.O. Box 97 Barron, WI 54812-0097PH: (800) 771-8387FAX: (715) 449-5052

ISOLATESDo you want us to save an isolate (s)? YES

If so, what genus? ______________________________Specific lab to send isolates to? ___________________

* Required fields

NOTE: The culture is only set up for Moraxella bovis and Moraxella bovoculi when aerobic culture is requested. Mycoplasma culture can also be requested for the isolation of Mycoplasma bovis, which can also be used to culture other hardy Mycoplasmas; however the bacteriology section cannot culture Mycoplasma bovoculi.

Date samples taken*______________________________

1. ___________________________________________________________________________________________________________

2. ___________________________________________________________________________________________________________

3. ___________________________________________________________________________________________________________

4. ___________________________________________________________________________________________________________

5. ___________________________________________________________________________________________________________

6. ___________________________________________________________________________________________________________

7. ___________________________________________________________________________________________________________

8. ___________________________________________________________________________________________________________

FM-CL-SUB-27 In Use: 5/7/2020 SOP: ACASEREVIEW

Date samples sent*_______________________________

MEDIAPCR testing: M6 Media Culture: Bacterial transport media

Culture PCR Culture & PCR