REPTILE and AMPHIBIAN SUBMISSION FORM Owner Name: Animal Name: Species: Age: Sex: Date: Specimen Source (Please Circle) 411 East McDermott Drive Ste B. Allen, Texas 75002 BLOOD SWAB FECES TISSUES FFPE Phone: (972)960-2221 Fax: (972)960-1997 www.vetdna.com PAYMENT ACCOUNT Acct # Check Enclosed Amount:_____________ Name Credit Card Address AMEX Discover Master Card Visa On File City Exp. Date: ______/______ State/ZIP _________________________________________ Phone# Name On Card _________________________________________ Email Credit Card Number Specimen Requirements: Blood - 0.1 ml whole blood Swab - Dry sterile swab LIVE ANIMAL TESTING ENVIRONMENTAL TESTING POST MORTEM DNA TESTS $20.00 each Aeromonas hydrophila E. coli Perkensis (Red leg disease) Entamoeba invadens Perkinsea Novel Alveolate Aspergillus Giardia Group 01 (NAG01) Atadenovirus-Agamid Helicobacter Reptillian/Herps Plasmodium (Malaria) Babesia Iridovirus Ranavirus Bartonella Klebsiella pneumonai Ringworm (Dermatophytes) Campylobacter Leptospirosis Salmonella Candida Leishmania Salmonella cotham Chelonia Mydas Herpesvirus (TPAP) Listeria monocytogenes Sarcocystis Chytrid Fungus (B. dendrobatidis) M.R.S.A Spironucleus elegans Chytrid Fungus (B. salamandrivorans) Mycobacterium chelonae Tortoise Herpes (Testudinid) Chlamydia Mycobacterium marinum Toxoplasma gondii Clostridium Mycobacterium ulcerans Tritrichromonas Coxiella burnetti Mycoplasma agassizzi Trypanosoma Cryptosporidium Genus Mycoplasma testudineum Tularemia (F. tularensis) Cryptosporidium varanii (Lizard) Ophidiomyces ophiodiicola (SFD) Yellow Fungus (CANV) Cryptosporidium serpentis (Snake) Ophionyssus Mite Devriesea agamarum Pasturella multocida Other _________________ PANEL TESTS RNA TESTS $25.00 (Overnight / 48 Hour Shipping Required) Reptile ‘Boid’ Panel: $60.00 Arenavirus (Inclusion Body Disease) Arenavirus, Nidovirus, Ophidian Paramyxovirus Nidovirus (Python) Tortoise Respiratory Panel: $60.00 Ophidian Paramyxovirus (FERLA Virus) M. agassizii, M. testudineum, Ranavirus, Reptile Borna Virus T. Herpesvirus Sunshine Virus Cryptosporidium Panel: $25.00 Cryptosporidium varanii, West Nile Virus Cryptosporidium serpentis For additional species and tests please visit online @ http://www.vetdna.com.