Form LSAD101F13.1 "Companion Animal/Equine/Other Submission Form" - Nova Scotia, Canada

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Download Form LSAD101F13.1 "Companion Animal/Equine/Other Submission Form" - Nova Scotia, Canada

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AHL LABORATORY ID
Companion Animal/Equine/Other
Submission Form
DATE RECEIVED
Animal Health Laboratory
NS Department of Agriculture
Date Sampled:
Physical Address
Date Submitted:
Hancock Building 65 River Rd.
Bible Hill, NS B2N 2P3
Sample Submitted by:
Owner
Veterinarian
PH. (902) 893-6540 / Fax (902) 895-6684
Other____________
Mailing Address
Send Report to:
Owner
Veterinarian
P.O. Box 890, Truro, NS
B2N 5G6
Other _____________________
How you would like to receive your report (check one)
Email
Fax
Mail
Owner Information
Veterinarian:
Name:
Veterinary Clinic:
Email:
Number of Specimens
Sample ID
Address:
No. Sent
Specimen Type
No. Received
□ __________
_______
Whole Carcass
_______
□ __________
_______
Whole Blood
_______
Postal Code:
□ __________
_______
Serum
_______
Phone:
Fax:
□ __________
_______
Urine
_______
_______
Feces
_______
□ __________
_______
Fresh Tissue
_______
Email:
□ __________
_______
Fixed Tissue
_______
□ __________
_______
Fluid
_______
□ __________
Animal
_______
Swab
_______
_______
Other: _____________
_______
□ __________
Identification_________________________
_______
Other: _____________
_______
□ __________
Species________________
_______
Other: _____________
_______
□ __________
Breed
______________
Sex
Male
Female Neutered/Spayed
Age ___ □ days □weeks □months □ years
Private Cremation
History and Special requests (additional space on back)
Euthanized Method_____________
(presenting illness, clinical signs, treatments, vaccinations etc.)
Description of Mass (size and shape, rate of growth, invasive etc.)
Dorsal
Ventral
Pathology
Bacteriology
Virology
Serology
Parasitology/Other
□ Necropsy
□ Aerobic culture
□ ____________
□ Fecal Flotation
______________
□ ____________
□ ____________
Histopathology
Aerobic culture/
______________
□ __________
sensitivity
□ _____________
□ ____________
□ ____________
□ Anaerobic culture
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
LSAD101F13.1
Page 1 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
AHL LABORATORY ID
Companion Animal/Equine/Other
Submission Form
DATE RECEIVED
Animal Health Laboratory
NS Department of Agriculture
Date Sampled:
Physical Address
Date Submitted:
Hancock Building 65 River Rd.
Bible Hill, NS B2N 2P3
Sample Submitted by:
Owner
Veterinarian
PH. (902) 893-6540 / Fax (902) 895-6684
Other____________
Mailing Address
Send Report to:
Owner
Veterinarian
P.O. Box 890, Truro, NS
B2N 5G6
Other _____________________
How you would like to receive your report (check one)
Email
Fax
Mail
Owner Information
Veterinarian:
Name:
Veterinary Clinic:
Email:
Number of Specimens
Sample ID
Address:
No. Sent
Specimen Type
No. Received
□ __________
_______
Whole Carcass
_______
□ __________
_______
Whole Blood
_______
Postal Code:
□ __________
_______
Serum
_______
Phone:
Fax:
□ __________
_______
Urine
_______
_______
Feces
_______
□ __________
_______
Fresh Tissue
_______
Email:
□ __________
_______
Fixed Tissue
_______
□ __________
_______
Fluid
_______
□ __________
Animal
_______
Swab
_______
_______
Other: _____________
_______
□ __________
Identification_________________________
_______
Other: _____________
_______
□ __________
Species________________
_______
Other: _____________
_______
□ __________
Breed
______________
Sex
Male
Female Neutered/Spayed
Age ___ □ days □weeks □months □ years
Private Cremation
History and Special requests (additional space on back)
Euthanized Method_____________
(presenting illness, clinical signs, treatments, vaccinations etc.)
Description of Mass (size and shape, rate of growth, invasive etc.)
Dorsal
Ventral
Pathology
Bacteriology
Virology
Serology
Parasitology/Other
□ Necropsy
□ Aerobic culture
□ ____________
□ Fecal Flotation
______________
□ ____________
□ ____________
Histopathology
Aerobic culture/
______________
□ __________
sensitivity
□ _____________
□ ____________
□ ____________
□ Anaerobic culture
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
□ _____________
□ _____________
□ ____________
□ ____________
LSAD101F13.1
Page 1 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
History and Special requests
Laboratory Use Only:
Verification of
AHL Lab ID:
receipt in Lab
No. Received in
Specimen Type
Lab
Whole Carcass
Whole Blood
Serum
Urine
Feces
Fresh Tissue
Fixed Tissue
Fluid
Swab
Other:
Other:
Other:
Received in lab by:
Date:
LSAD101F13.1
Page 2 of 2
Results derived from testing may be used for statistical surveillance of animal health in Nova Scotia. Laboratory Services complies with the
Federal Health of Animals Act. Laboratory Services will make all reasonable efforts to keep personal information confidential and not disclose
personal identifiers.
Page of 2