Sample Submission Form

Sample Submission Form Avian Diseases Research Laboratory North Carolina State University College of Veterinary Medicine Raleigh, NC 27606

Instructions: Please provide as much information as possible. Avoid using non-standard abbreviations. Contact Dr. David Ley 919-513-6269 or Sile Huyan (laboratory) 919-513-6249 if you have any questions.

Company name: ______

Address: ______

Contact Person: ______Phone # ______

e-mail : ______

Billing address or Account #: ______

Species: Chicken: Breeder ______Layer ______Broiler ______

Turkeys: Breeder ______Meat ______Other (specify) ______

Flock Identification: Farm name: ______

Flock number: ______

Number of birds: ______Sample site: ______

Age/Sex: ______No. Samples: ______

Tests requested: MG PCR _____ MS PCR _____

MI PCR _____ MM PCR _____ Culture ______

History/Treatments (i.e. antibiotics, vaccinations, drinking water and feed additives) Note: antibiotics and some drinking water additives may adversely affect isolation of mycoplasmas.

Do not write below this line. For laboratory use only.

ADRL No: ______Date Received: ______

Sample submission media type: swab______transport medium______

broth medium______other______