Fill and Sign the Student Medical Certificate Griffith University Form

ANIMAL HEALTH LABS LABORATORY FORM 2230 OLD PENITENTIARY ROAD BOISE, ID 83712 PHONE: (208) 332-8570 / FAX: (208) 334-4619 www.agri.idaho.gov Date Sent: ___________________ Via: ________________________ (Mail; Bus; Carrier; etc.) Date Bled/Collected: _______________________________________ By (date) _________________ Export to LAB USE ONLY Accession # ___________________ Number of Specimens _______ Specimen Type __________________ Number of Animals _______ LAB: †Serology †Virology †Bacteriology Refer to: ________________________________________________ VETERINARIAN / CLINIC OWNER Veterinarian Name: _____________________________________________________ Name: ____________________________________________________________ Clinic Name: __________________________________________________________ Address: __________________________________________________________ Address: _____________________________________________________________ _____________________________________________________________ __________________________________________________________ County Animal Resides: ______________________________________________ Type of Specimen: † Serum † Tissue † Swab Milk Other (Specify) __________________________ Total Number of Specimens: ___________ Species: ________________________ Breed: ___________________________ Sex: F M Age: Weight: ________ Number of Animals in Group: Number Sick: All results are mailed to the Clinic. FAX (#) ( ) Number Dead: Date/Hour of Death: _____________________________________ You may request results by PHONE (#) ( ) . Please Note: There is a $1.00 per page fee for all faxes. or by HISTORY (Including Vaccinations; Symptoms; Sickness Duration; Treatment; Necropsy Lesions, etc.): _________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ TEST(S) REQUESTED (If not listed below):__________________________________________________________________________________ A complete animal identification is required. Anaplas. Animal ID (required) c.ELISA Please check the box or circle the test procedure requested below. Bluetongue †AGID †cELIS A 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) Continuation form attached: yes no Bovine Leukosis † AGID † ELISA BVD I&II † SN † PCR †ELISA PI †EHV ------†EVA SN † IBR †PI3 †RSV Johne’s † ELISA †Culture † PCR Lepto Panel of 6 AI †AGID †ELISA Salmn. Pullm. --MS West Nile Virus Brucella † Ovis