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)
AVI (ostrich)
Owner
Sender
Other*
Fax:
Other (specify):
Type of specimens:
Age of Animal:
Sex:  M  F
No. of specimens:
Date collected:
TEST/S REQUIRED (PLEASE INDICATE WITH X)
SEROLOGY
Brucellosis: MRT
Brucellosis: RBT, CFT, SAT
ELISA tests
BVD antibody
BVD antigen
PRRS antibody
CSF antibody
IB
Avian Influenza
IBR
EBL (BLV)
HI (Haemagglutination tests)
NCD
AI H5
AI H6
AI H7
Other
Brucella ovis (CFT)
Dourine (CFT)
Leptospirosis (MAT)
MG (Agglutination test)
MS (Agglutination test)
VIROLOGY
Virus Isolation
TOXICOLOGY
Nitrites / Nitrates spot test
Prussic acid screening
Ryegrass toxicity screening
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

BACTERIOLOGY
Culture and identification (aerobic)
Culture and identification (anaerobic)
Antibiogram
FOOD SAFETY
Export List
Import List
Aerobic plate count
Pseudomonas
Lactobacillus
Coliforms & E.coli
Enterobacteriaceae
Yeasts and Fungi
Staphylococcus aureus
Listeria monocytogenes
Salmonella spp.
B. subtilis growth inhibition
Water
Aerobic plate count
Faecal coliforms & E.coli
Faecal Streptococci
Export List (water)
Total Coliforms
REPRODUCTION
Sheathwash: Trichomonas & Campylobacter
Semen evaluation
Morphology & motility
Morphology, cytology, bacteria
Cytology & bacteria
Morphology
Total Bacterial Count
MASTITIS
Culture, ID
Antibiogram
HISTOPATHOLOGY
Process, stain & examine
Process & stain
BIOCHEMISTRY
Serum / Plasma samples
Ca
P
Mg
Cu
Fe
Zn
Na
K
Cl
Protein (total & albumin)
Serum only
Gamma globulin
Enzymes: GGT
BUN
Enzymes: AST
Whole Blood
Selenium
Haematocrit
Enzymes: CK
Organ samples
Cu
Fe
Ca
P
Zn
Mg
Mn
Se
Mo
Feed samples
Ca
Mg
Fe
Mn
P
Zn
Na
Se
K
Mo
Cu
Bone samples
Ca
P
Mg
Mn (incl. Bone Ash)
Cu
Fe
Zn
Se
Cr
Medicaments
Cu
Zn
Mn
PCR
AIV
NDV
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 4
COMPILED BY:
FH Dreyer (TLM)
ACCEPTANCE:
J Banda (QM)
AUTHORIZATION:
S Gers (DD) Acting
AUTHORIZATION DATE:
2012/02/07
UNCONTROLLED COPY
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