primary submitter: karen moore; jaimie...
TRANSCRIPT
Enhanced Surveillance for Equine Arbovirus Disease ProjectRequest for Laboratory Examination – INITIAL / FIRST VISIT
OWNER Name:
Property Name …………………………………………………….
PIC Property address/geographic location of affected animals
....................................................................................... Postcode
Phone (….)………………………………………Fax (….) …………………………………………………….
Email: ……………………………………………………….
Office OnlyHerd No.
Date of Investigation
…..../….../…...
PRIMARY SUBMITTER: Karen Moore; Jaimie Hunnam
INVESTIGATOR/VETERINARIAN
Name:……………………………………………………………………………………..……………………………………..
Practice or District Office Name: …………………………………………..……………………………………………………………….
Postal Address:…………………….................................................................................................... Postcode…………………
Phone (….) ……………………….. Fax (….) …………………………….. Email: …………………………………………………..
Species
EQUINE
Breed
………………………
Age
………………….……
Sex
………………….……
Total No. Sick
…….………………
Total No. Dead
…….……………Additional history/Comments
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
Number and nature of samples(tick and indicate number of samples)
Investigations required
Blood (Whole) x Hendra PCR Arbovirus panel (Ross River, pan-flavivirus serology (MVEV, Kunjin virus if indicated)) Blood (EDTA) x
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Enhanced Surveillance for Equine Arbovirus Disease Project – Request for Laboratory ExaminationCLINICAL ASSESSMENT OF SAMPLED ANIMALS
Animal name Microchip number Rectal temperature Samples collected(tick)
Blood: EDTA □ Whole □
Blood: EDTA □ Whole □
Blood: EDTA □ Whole □
Blood: EDTA □ Whole □
Blood: EDTA □ Whole □
Blood: EDTA □ Whole □
Please forward samples to – Veterinary Diagnostic Services, AgriBio Specimen Reception, 5 Ring Road, La Trobe University Bundoora, Victoria, 3083 Phone: (03) 9032 7515Fax: (03) 9032 7604 Email: [email protected] more information please contact the duty pathologist on (03) 9032 7515
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