* Please see instructions for FAVN submission and reporting at http://www.ksvdl.org/rabies-laboratory/. This submission form is a legal and binding contract
between KSVDL and the submitting entity. Specimens submitted become the property of the KSVDL. 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 60 days. Version 06/2015
Results are reported on this form. Please complete on-line and printout. If handwritten, print clearly. Handwritten information is
subject to interpretation by laboratory personnel. Once submitted, information cannot be altered*. Required fields are bolded.
Destination of animal being exported: _______________________________________________
Destination information is for laboratory report distribution only.
Submitting Clinic: _______________________________________________ Phone: _____________________
Veterinarian Name: ______________________________________________ Fax: _______________________
Clinic Mailing Address: ___________________________________________
City: _________________________ State/Country: _________ / _______________ Zipcode:
First ________________________ Last ________________________________________________
Animal Name: ________________________________________________________________________________
Microchip Number: ___________________________________ Serum Draw Date (mm/dd/yyyy): ____/_____/_______
If there are two microchip numbers, only the first one will be on the result label.
Species/Breed: ___________________________________________ Sex: M F Age:_________________
Rabies Vaccination History:___________________________________________________________________________
Vaccination history is for laboratory reference only. Please include up to three recent vaccinations dates if available.
Samples and test data may be used for general research without compromising client confidentiality.
Signature of Veterinarian: ________________________________________ Date (mm/dd/yyyy):_____/_____/_______
Signature affirms that the above information is correct and the microchip number has been verified.
Test will be cancelled if sample tube is unlabeled or arrives without the microchip number*.
Rabies Antibody Titer for Export Animals
2005 Research Park Circle
Payment Total: __________________________
STAT: Courier: Priority / 2-Day / Ground / NBC
For Lab Use Only: Opened by: __________________________ Processed By: _______________________________
Transferred By: ______________________ Payment Received: ___________________________
ANIMAL HEALTH LAB-U OF GUELPH
UNIV. OF GUELPH, BOX 3612
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