Email ______________________________________ Email _________________________________________________ □ fax, □ email, or □ mail □ Add’l Copy to ________________________________________ Reference #__________________________ Date sample(s) taken____________ Date shipped _________________ □ Cattle □ Turkey □ Horse □ Chicken □ Swine □ Psittacine ___________ □ Sheep □ Goat □ Rabbit □ Plant or Feed □ Other ____________ Movement Sample ____________________________ (Specify test methods below) Destination / Date of movement Location of Animal(s) ____________________________ (county, state) Project/Trial □ CAHFS contact ______________________ Production Class ________________________ (i.e. beef, dairy, calf ranch, etc.) #in group/hse #in herd/flk #sick #died History (clinical signs, nutrition, housing, vaccination, treatment, production level, etc. Use next page if more space is needed.): Duration of Illness ___________ Date of death: _____________ Euth? Yes □ No □ Insured? Yes □ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ________________________________________________________________________________________________ (continue on next page if necessary) Disease(s) or condition(s) suspected: Animal/Specimen Information (continue on back) Animal ID/Name Breed Sex (F/M) Age Qty Specimen Type Test(s) Requested CAHFS, Davis University of California, Davis 620 W. Health Sciences Dr Davis, CA 95616 General Info: (530) 752-8700 FAX (530) 752-6253 CAHFS, Turlock University of California, Davis 1550 N. Soderquist Turlock, CA 95381 General Info: (209) 634–5837 FAX (209) 667–4261 CAHFS, Tulare University of California, Davis 18830 Road 112 Tulare, CA 93274 General Info: (559) 688-7543 FAX (559) 686-4231 CAHFS, San Bernardino University of California, Davis 105 West Central Avenue San Bernardino, CA 92408 General Info: (909) 383-4287