Laboratory Use Only Case No.
Pathology Inventory
Request Form Initials_____________
College of Veterinary Medicine Page
Page
1 1 Fixed______________
Fresh______________
Veterinary Diagnostic Laboratory
Other___________________________________________________________
1850 Christensen Dr | Ames, IA 50011-1134
515-294-1950 | Fax 515-294-6961 | www.vetmed.iastate.edu/vdl _______________________________________________________________
VETERINARIAN__________________________________________________
Test Selection & Sample Type Identification on Back >
Clinic______________________________________________________________
Address____________________________________________________________ ANIMAL LOCATION: Premises, Herd and Submission-Level Identifiers
City, State & Zip______________________________________________________
SITE NAME____________________________________________________
Phone__________________________ Fax___________________________
Address_________________________________________________________
Email______________________________________________________________
City, State & Zip___________________________________________________
Accreditation # (if regulatory)_____________________________________________
County____________________________ Country_____________________
❏ If Owner Name and Address are same as Animal Location (include info under Site Name)
Premises ID# (attach premises ID bar code sticker if available)
OWNER__________________________________________________________
Address____________________________________________________________
City, State, & Zip_____________________________________________________
Third-Party Billing (pre-approved) Affiliates (list clinic names or codes)
Lot or Group ID______________________
Premises Type
Source or Flow ID____________________ (Best Description)
Reference (Other)____________________ ❏ Boar Stud/Breeding Herd
Special Reporting Requests
__________________________________ ❏ Collection Point (Slaughter/Market)
❏ Fax____________________________________________________________ __________________________________ ❏ Farrow to Feeder/Finish
❏ Email__________________________________________________________ ❏ Nursery
Vaccine Usage
❏ Grow-Finish (or Wean to Finish)
Vaccine Name
Date
Given Dose
❏ Isolation or Growing
Replacement Stock
Date Collected __________________________________________________ ____________________________
❏ Cow/Calf
PATIENT INFORMATION ❏ Feedlot
Animal ID________________________________________________________ ❏ Dairy
____________________________
(Sample ID Continuation Form available if listing many ID #’s)
❏ Caprine/Ovine
Species _____________ Breed _____________ Gender___________ Reason for Test
(Required) ❏ Equine
❏ General Diagnostics ❏ Companion Animal
Age/Unit _____________ ❏ days ❏ weeks ❏ months ❏ years ❏ adult ❏ Surveillance ____________________________
(Required) (Age from Birth)
Location ________________________________________________________
❏ Research ❏ University or Research Center
❏ Other__________________________ ❏ Other_____________________
Weight _______________ ❏ lb ❏ g ❏ kg (Specify reason for testing if for official
regulatory purposes) _____________________________
(Weight Unit )
CLINICAL SIGNS/SYNDROME (Check All That Apply – Required )
❏ CNS ❏ Enteric ❏ Lameness ❏ Reproductive ❏ Respiratory ❏ Sudden Death ❏ Systemic
❏ Other_______________________________________________________________________________________________________
CLINICAL SIGNS, TREATMENT & RESPONSE, FEEDING, MANAGEMENT, POST MORTEM FINDINGS, DIFFERENTIAL DIAGNOSIS
# At risk_________ ❏ # or ❏ % Sick________ ❏ # or ❏ % Dead_________
The ISU VDL is a fully accredited laboratory by the American Association of Veterinary Laboratory Diagnosticians and a member of the National Animal Health Laboratory Network. A complete
description of ISU VDL’s diagnostic services, submission guidelines, client confidentiality policy, and the contractual terms associated with the requests and performance of diagnostic services at
the ISU VDL are available at the ISU VDL website (www.vetmed.iastate.edu/vdl). Diagnostic specimens submitted for testing are retained according to the testing section policy. Serology 2 wks;
Molecular 3 wks; Analytical – tissue 6 wks, fluid 2 wks from the date received should the need for additional testing arise.
Page 1
Biopsy/Source __________________________________________ Laboratory Use Only Case No.
______________________________________________________ No. Samples
______________________________________________________
______________________________________________________
Number of Animals Sampled ______ ❏ Test Individually ❏ Pool Samples
(Required)
SUBMISSION DETAILS
# Submitted alive __________ # Submitted dead __________ # of Fetuses __________ Other (specify) ______________________________________
# On Ice # Fixed # On Ice # Fixed # On Ice # Fixed # On Ice
Brain ______ ______ Kidney ______ ______ Intestine ______ ______ Feed ______ ❏ Expected PRRSV Neg
Heart ______ ______ Spleen ______ ______ Colon ______ ______ Water ______
❏ Expected PEDV Neg
Lung ______ ______ Tonsil ______ ______ Serum ______ ______ Feces ______
Other ____________________
Liver ______ ______ Lymph node ______ ______ Blood ______ ______ Swabs ______
EXAMINATIONS REQUESTED (Unless “Discretion of Diagnostician” is marked, ONLY tests indicated will be performed)
❏ Discretion of Diagnostician – THE DIAGNOSTICIAN’S JUDGMENT WILL DETERMINE TESTS PERFORMED
❏ Gross Pathology Specific interest______________________________________________________________________________________________
❏ Histopathology Specific interest______________________________________________________________________________________________
❏ Immunohistochemistry Specific interest______________________________________________________________________________________________
❏ Bacteriology ❏ Culture/ID ❏ Sensitivity ❏ Fungal culture
❏ Specify organisms/tests and instructions ______________________________________________________________________
❏ Serotype/Genotype - Specific agent/instructions ___________________________________________________________
❏ Molecular Diagnostics ❏ PCR - Specify organisms/tests and instructions ________________________________________________________________
___________________________________________________________________________________________________________
❏ IAV (USDA Surv)
❏ Sequencing^ - Specify organisms/tests and instruction ______________________________________________________
___________________________________________________________________________________________________________
❏ Virology Virus isolation - specify organism//test and instructions ________________________________________________________
___________________________________________________________________________________________________________
❏ Parasitology^ Specific organism/test________________________________________________________________________________________
❏ Analytical Chemistry Specify agents/micronutrients _________________________________________________________________________________
Services
___________________________________________________________________________________________________________
Rabies examination - Please use our Rabies form.
Additional Information
or Test Requests:
^ Testing performed in part or in total at a Referral Laboratory.
The ISU VDL is a fully accredited laboratory by the American Association of Veterinary Laboratory Diagnosticians and a member of the National Animal Health Laboratory Network. A complete
description of ISU VDL’s diagnostic services, submission guidelines, client confidentiality policy, and the contractual terms associated with the requests and performance of diagnostic services at
the ISU VDL are available at the ISU VDL website (www.vetmed.iastate.edu/vdl). Diagnostic specimens submitted for testing are retained according to the testing section policy. Serology 2 wks;
Molecular 3 wks; Analytical – tissue 6 wks, fluid 2 wks from the date received should the need for additional testing arise. 3/2023 Page 2
