Southeastern Louisiana University
Veterinary Consult Request Form
Requestor’s Name: Date:
Contact Information of Requester:
Phone:
Email:
Primary Investigator/Instructor Name:
Phone:
Email:
Location of Animals (Bldg & Room Number):
Species:
Identification on Cage/Aquarium:
Age of Animals:_____________________________ Male or Female (circle one)
Nature of Medical Concern:
Observed Symptoms:___________________________________________________
Date Symptoms First Observed:
Please sign and date and submit this form to Dr. Penny Shockett, IACUC Chair.
Please Note: 1) Veterinarian may contact requestor for animal access.
2) If evaluation is required in less than 72 hours, please contact
Dr. Dale Peyroux, D.V.M, directly at Office: 985-345-5157 or Cell: 985-320-6232.
Signature: ____________________________ Date:
Implemented 7-30-08
Ver. 1
click to sign
signature
click to edit
![]()
