WESTERN CAPE PROVINCIAL VETERINARY LABORATORY : STELLENBOSCH
Private Bag X5020, Stellenbosch, 7599
Helderfontein, Helshoogte Road
tel: +27 21 887 0324 fax: +27 21 886 5341
www.elsenburg.com | www.westerncape.gov.za
SAMPLE SUBMISSION FORM
FOR LAB USE ONLY :
Fee:
Rec. no:
Date:
Time:
RPO:
LAB REF
Sender code
Owner code
DETAILS OF OWNER AND SENDER
Owner
Contact person
Farm name
Address
Code:
Tel
Fax
Cell
Email
Sender Reference:
Sender
Co. or Clinic
Address
Tel
Fax
Cell
Email
REPORT TO:
Owner
* Account
to Other:
Name:
Postal address:
SPECIES
BOV
OVI
Sender
CAP
RESULTS BY:
Mail
Phone
Fax
Code:
Email
ACCOUNT TO:
Tel:
PORC
EQUI
AVI (poultry)
AVO (ostrich)
Owner
Sender
Other*
Fax:
Other (specify):
Type of specimens:
Sex:  M  F
Age of Animal:
No. of specimens:
Date collected:
TEST/S REQUIRED (PLEASE INDICATE BELOW)
SEROLOGY
Brucellosis: MRT
Brucellosis: RBT, CFT, SAT
ELISA tests
BVD antibody
BVD antigen
Avian Influenza
IBR
EBL (BLV)
HI (Haemagglutination tests)
NCD
AI H5
AI H6
AI H7
Other
Brucella ovis (CFT)
Dourine (CFT)
Leptospirosis (MAT)
VIROLOGY
Virus Isolation
TOXICOLOGY
Nitrites / Nitrates spot test
Prussic acid screening
Ryegrass toxicity screening

BACTERIOLOGY
Culture and identification (aerobic)
Culture and identification (anaerobic)
Antibiogram
BIOCHEMISTRY
Serum / Plasma samples
Ca
P
Mg
Cu
Fe
Zn
MASTITIS
Culture and identification
Antibiogram
Serum only
Gamma globulin
Enzymes: GGT
FOOD SAFETY
Export List
Import List
Aerobic plate count
Lactobacillus
Coliforms & E.coli
Enterobacteriaceae
Yeasts and Fungi
Listeria monocytogenes
Salmonella spp.
B. subtilis growth inhibition
Water
Aerobic plate count
Faecal coliforms & E.coli
Faecal Streptococci
Whole Blood
Selenium (Se)
Export List (water)
Total Coliforms
PARASITOLOGY
Faecal egg & oocyst count
Faecal egg & oocyst count (pooled sample)
Fluke egg count (conical & liver)
Internal parasite ID
External parasite ID
Larval culture and ID
FECR test
REPRODUCTION
Sheathwash: Trichomonas & Campylobacter
Semen evaluation:
Morphology & motility
Morphology, cytology, bacteria
Cytology & bacteria
Morphology
Semen: Total Bacterial Count
PCR (Molecular)
Avian Influenza Virus (AIV)
Newcastle Disease Virus (NDV)
HISTOPATHOLOGY
Process, stain & examine
Process & stain
Na
K
Cl
Protein (total & albumin)
BUN (Blood Urea nitrogen)
Enzymes: AST
Enzymes: CK
Haematocrit (PCV)
Organ (Liver; Kidney) samples
Cu
Fe
Zn
Mn
Biopsy (Liver) samples
Cu
Fe
Feed samples
Cu
Fe
Ca
P
Ca
Mg
Mn
Zn
Mg
P
Zn
Mn
Na
Se
K
Bone samples (mineral analysis includes bone ash)
Ca
P
Mg
Cu
Fe
Zn
Mn
Medicaments
Cu
Zn
Mn
Se
Cr
POST MORTEM
Adult large animal (e.g. cattle,horse,pig)
Small stock,dog,cat, immature large animal
Poultry, Birds & Exotic animals
Ostrich: immature
Ostrich: adult
Foetus
Additional Animal / Specimen information (e.g. breed, ID no.) / History / Special requests / Etc.:
P-SR-F-001
Edition 6
COMPILED BY:
FH Dreyer (TLM)
ACCEPTANCE:
R Pieterse (QM)
AUTHORIZATION:
D Roberts (DD) Acting
AUTHORIZATION DATE:
2013/10/07
UNCONTROLLED COPY
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