Department of Primary Industries
DAFORM1
DEPI VICTORIA – Veterinary Diagnostic Services
AgriBio Specimen Reception
5 Ring Road, La Trobe University.
Bundoora, Victoria, 3083
Phone: (03) 9032 7515 Fax: (03) 9032 7604
Email: vet.diagnostics@depi.vic.gov.au
Request for Laboratory Examination
Accreditation # 14477
Lab Only
Specimen No.
OWNER Name: ..........................................................................................................................................................
Property Name ……………………………………………………..PIC
Property Address .........................................................................................................................................................
................................................................................................ Postcode ...................................................................
Phone (….) ........................................................... Fax (….)
Duty Path: ...................
...................................................................................
SENDER
Name:……………………………………………………………………………….
Practice or District Office Name:..... ………………………………………………………
Copies
DVO
OTHER
specify
Senders Reference
……………………………..
……………………
Date of Collection
Postal Address: ................................................................................................................... Postcode ...........................
.……./……../…………
Phone (….) ............................ Fax (….) ............................ Email: ...............................................................................
Reason for
Submission
Diagnostic

Charged to Sender
Species
……………………………………………
Significant Disease Investigation (SDI)

Approved by DEPI Officer:……………………………
Breed
.......................... ……………
Age
Health

Certification / Export
Sex
…………………
…...
…………….
DEPI Surveillance Project

…………………………………
No. at Risk
…………
No.Sick
No. Dead
…………...
…………..
History, Clinical assessment & Post Mortem findings
…………………………………………………………………………………………………….………………………………………………..
……………………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………………...
……………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………..
Provisional
Diagnoses
1.
3.
2.
Animal Identification
4.
Nature and No. of Specimens
Investigations requested
Signature:…………………. Date…./…./…...
Authorised By: Mark Hawes
Version: 1.55.2 Date:
Control Status: DRAFT
Group: Diagnostic Accessions
Doc ID#: 13697
Page: 1 of 2
Department of Primary Industries
DAFORM1
DEPI VICTORIA – Veterinary Diagnostic Services
AgriBio Specimen Reception
5 Ring Road, La Trobe University.
Bundoora, Victoria, 3083
Phone: (03) 9032 7515 Fax: (03) 9032 7604
Email: vet.diagnostics@depi.vic.gov.au
Number: 14477
Tube No.
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Authorised By: Mark Hawes
Version: 1.55.2 Date:
Control Status: DRAFT
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Group: Diagnostic Accessions
Doc ID#: 13697
Page: 2 of 2