Ocala Veterinary Diagnostics Submission Form General Submission Form An automatic email of this form will be sent to the submitting veterinarian. Please check the Spam Folder & mark as Not Spam for future requests. Submitting Veterinarian Clinic Name Street Address City State Zip Code Phone Submitting Vet’s Signature Email New or Returning Veterinarian New Returning-Info is on fileVeterinarian Accreditation # FL Veterinarian ID Owner First Name Owner Last Name Street Address City State Zip Code Owner Phone Owner Email Animal Identification:Name Breed Sex Male Intact Female Intact Castrated Male Spayed FemaleAge or Date of Birth Microchip or Registration Number Test(s) RequestedHEM/CHEM Panels -Select-CBCCBC/IgG (semi)Colic-CBC, Chem, LacCBC/Chem/IgG (semi)Health-CBC, ChemMedicine-CBC, Cr, LytesNeonatal-CBC, Glu, Cr, LytesPCV/TPChemistry Panel -Select-BUN/CreateComprehensive Chemistry PanelElectrolyte + Chemistry PanelGlucoseIgG: QuantitativeIgG: Semi-quantitativeMuscle EnzymesPeritoneal LactatePeripheral LactateSerum Amyloid AEIA/COGGINS-*May select multiple test types*- 2 HR ELISA (blood must be at the lab by 3 pm) Next Day AGID 72 HR AGID# of Test Samples-2 HR # of Test Samples-Next Day # of Test Samples-72 HR Parasitology/Virology -Select-C. Difficile A/BC. PerfringensEquine Influenza VirusFecal FloatOccult BloodRotavirusEndocrinology -Select-ACTHACTH w/insulinACTH/Cort/InsulinBile AcidsCortisol BaselineCushing’sEstrone SulfateInsulin BaselineP4 ProgesteroneT4 ThyroidTestosteroneCytology -Select-Gram StainCyt. Slide OnlyPeritoneal Fluid AnalysisPleural Fluid AnalysisSynovial Fluid AnalysisComplete UrinalysisWBC/TPMicrobiology - On Antibiotics? Yes NoMicrobiology -Select-BloodFluidFluid w/SensitivityFungalFungal w/SensitivityNasalNasal w/SensitivitySalmonellaStallionStallion w/SensitivityTTW w/SensitivityTrans Tracheal WashUrineUrine w/SensitivityWoundWound w/SensitivityUterine (Plated/Growth)Uterine CytologyUterine Cytology w/SensitivityUterine ONLY SensitivityHistopathology - Select -Histopathology Level 1Histopathology Level 2REQUIRED-click here to complete details on HistopathologySpecial Testing -Select-Allergy Test-RegionalCEM CultureCEM TiterEHV-5 UKEMP TiterEVAHYPPKaryotypingLawsonia SerologyLymes Disease TiterNI Antibody Screen (call lab prior to sample collection)Piroplasmosis Complement FixationStrep equi PCR/CultStrep M ProteinDrug Screens -Select-Drug Screen-Level 1Drug Screen-Level 2Miscellaneous Services -Select-AutoclaveClean & AutoclaveSharps DisposalSpecial Instructions Submit Form