Clinical Immunology/Flow Cytometry
Submission Form
Kansas State Veterinary Diagnostic Laboratory
1800 Denison Avenue, Mosier D117 Manhattan, KS 66506
Phone: (785) 532‐5650 Toll Free: (866) 512‐5650
Fax: (785) 532‐4835
BILL TO
Client
Owner
Third Party
Owner/Third Party to Receive Results?
Y
N
Third Party Contact Info:
_______________________________________________________________
Account# ______________
Internal Ref # ________________
OWNER/PRODUCER
Veterinarian:_________________________________________________
Owner Name:______________________________________________________
Clinic Name: ______________________________________________________________
Farm Name:__________________________________________________
Address:_____________________________________________________
Address:__________________________________________________________
City, State:
City, State:
Zip: ___________
Phone:
Fax:__________________________
Zip:___________________
Phone:
Cell: ________________________
Email: ______________________________________________________
Fax or Email:_______________________________________________________
Send Results Via (Check all that apply):
Also Send Results to Owner:
Fax
Email
Online
Animal/Specimen Information
Sex Codes: M=Male MC=Castrated Male F=Female FS=Spayed Female Age Codes: Y=Years M=Months W=Weeks D=Days
ANIMAL ID
SPECIES
Please Check Ordered Test (Sample Requirement - Species)
Test
*PSAIg: Platelet Surface Antibody
(2-3 mL EDTA blood) - Canine & Equine
BREED
SEX
AGE
DATE & TIME OF BLOOD DRAW
Test
Immunophenotyping of Fluids
(1 ml of pleural, peritoneal or CSF fluid) - Canine, Feline, Bovine & Equine
*We must receive PSAIg samples within 24 hours of being drawn.
RBIg: Red Blood Cell Surface Antibody
Immunophenotyping of Lymph Node
(2-3 mL EDTA blood) - Canine & Equine
(minimum 2-3 needle biopsies places in 1 ml of saline with 0.1 ml
autogenous serum added) - Canine, Feline & Equine
Antibody to Penicillin (Equine IMHA)
Immunoflourescent Antibody on Bone Marrow
(1-2 ml of serum) - Equine Only
(minimum of 2 slides) - Canine, Feline & Equine
ANA: Anti-Nuclear Antibody Test
Immunoglobulin Quantitation Panel (IgM and IgG)
(2-3 ml of serum) - Canine, Feline &
Equine
(1-2 ml of serum or colostrum) - Equine Only
RF: Rheumatoid Factor
Quantitation of IgG by Radial Immunodiffusion
(1-2 of serum) - Canine only
(1-2 ml of serum or colostrum) - Equine & Camelids
Immunophenotyping of Blood
(1-3 ml of blood) - Canine, Feline & Equine
Quantitation of IgM by Radial Immunodiffusion
Immunophenotyping of Bone Marrow
(bone marrow aspirate in EDTA) - Canine, Feline & Equine
(1-2 ml of serum or colostrum) - Equine only
Canine RBCs Antibody/ANA/RF Panel
(1-2 ml serum and 1-2 whole body in EDTA) - Canine only
History:
This submission form is a legal and binding contract between KSVDL and the submitting entity. All fees, to include collection fees, are the responsibility of the submitting entity and all entities must adhere to the billing
policy. Fees may be paid by check (payable to KDAS), credit card, money order, or electronic bank transfer. A 1.5% finance charge will be assessed on all charges over 30 days 12/4/2013