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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 FORM MADISON 445 Easterday Lane, Madison, WI 53706 PH: (800) 608-8387 FAX: (608) 504-2594 BARRON 1521 E. Guy Ave., P.O. Box 97 Barron, WI 54812-0097 PH: (800) 771-8387 FAX: (715) 449-5052 ISOLATES Do 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* _______________________________ MEDIA PCR testing: M6 Media Culture: Bacterial transport media Culture PCR Culture & PCR
