<p> Sample Submission Form Avian Diseases Research Laboratory North Carolina State University College of Veterinary Medicine Raleigh, NC 27606</p><p>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.</p><p>Company name: ______</p><p>Address: ______</p><p>Contact Person: ______Phone # ______</p><p> e-mail : ______</p><p>Billing address or Account #: ______</p><p>Species: Chicken: Breeder ______Layer ______Broiler ______</p><p>Turkeys: Breeder ______Meat ______Other (specify) ______</p><p>Flock Identification: Farm name: ______</p><p>Flock number: ______</p><p>Number of birds: ______Sample site: ______</p><p>Age/Sex: ______No. Samples: ______</p><p>Tests requested: MG PCR _____ MS PCR _____ </p><p>MI PCR _____ MM PCR _____ Culture ______</p><p>History/Treatments (i.e. antibiotics, vaccinations, drinking water and feed additives) Note: antibiotics and some drinking water additives may adversely affect isolation of mycoplasmas.</p><p>Do not write below this line. For laboratory use only.</p><p>ADRL No: ______Date Received: ______</p><p>Sample submission media type: swab______transport medium______</p><p> broth medium______other______</p>