2009 submission form updated.pub (read-only)

TDA Laboratories, LLC
Mailing/Physical Address: Phone:
970.351.8102
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

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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.
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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: □ 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

Fecal/Urine
□ 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

Milk: □ 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 :
□ Milk/Serum—Elisa

□ 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