SAMPLE SUBMISSION FORM FOR DISEASE INVESTIGATION

For: The Assistant Director Disease Investigation Laboratory State Veterinary Hospital Complex Shimla-171001 +91 94180 85640 ------------------------------Veterinarian/Case Coordinator: Name of Hospital/ Dispensary/ Farm: District: Phone: OPD No. For Lab Use Only Lab ID Number: Samples Received

Sample Condition: Optimal Sub-optimal Sample Shipped via: Messenger Courier Non-diagnostic

Other

Owner’s Name and Address

Animal ID: Samples Submitted:

Species

Sex:

Age:

Date of Collection:

Tests Requested: Haemogram (Complete Blood CountCBC) Urine Test PullorumTesting Impression Smear Cytology Biochemistry Tests TLC, DLC, Hb, MCV, MCH, PCV, MCHC, ESR Haemoprotozoa Urine-Culture Brucellosis SAT/RBPT Biopsy Glucose, Liver Fn, Ca, P, etc.,

Faecal Sample

Skin Scrapping

Antibiotic Sensitivity TB Test Necropsy Renal Fn. Cholesterol

Milk-Mastitis / Milk- Culture JD Test Histopathology Other Tests:

DI reserves right to modify the tests requested for efficient case workup. Additional History, Vaccination status, treatment etc:

Condition(s) suspected: Certified that the specimen(s) submitted along have been collected by me from the animals described on the date indicated. Veterinarian’s / Case Coordinators Signature

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