Sample Submission

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Sample Submission

*Required fields.

Patient's Information

Pet's Name*

Owner's Name*

Species*

Breed*

Age*

Date*

Gender*

Clinician's Information:

Clinician*

Clinic*

Email for Report*

Previous Submission from this Patient?*

History:

Pertinent Case History*

Has the patient previously been treated with antibiotics (to your knowledge)?*

Yes No Unknown

Sample Source*:

Cornea Eyelid Conjunctiva Orbit Nasolacrimal Duct Intraocular Other

Tests*:

Aerobic culture (organism ID) Aerobic culture (organism ID and ocular AST) Aerobic culture (organism ID and systemic AST) Aerobic culture (organism ID, ocular and systemic AST) Anaerobic culture (organism ID)

Sample Submission/Microbiology Submission Form (hard copy also included in the collection kit/download the form)