RABIES DIAGNOSTIC REQUISITION

RABIES DIAGNOSTIC REQUISITION FORM

All Fields marked with * are mandatory

Click here on instructions to fill the Rabies Diagnostic Requisition Form

Step 1 : SPECIMEN SUBMITTED BY

Client Account Number *

Email Address *

Clinic/Agency Name

Address Line1 *

Address Line2

Phone Number *

Fax

City *

State *

Zip *

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Step 2 : SPECIMEN HISTORY

Kind of Animal *

Breed/Species

Age

Color/Description

Gender

Animal Location

State *

Town/City

County

Submitted animal’s vaccination status

Was the animal sick or acting strangely?

Clinical signs the animal exhibited

neurological disorder paralysis difficulty swallowing drooling aggression other

Date of Death

Date Submitted

Check if the owner is the same as the person who submitted the specimen

Owner/Complainant Name *

Phone *

Address Line 1

Address Line 2

City

State

Zip

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Step 3 : EXPOSURE HISTORY

Has the animal exposed any person? *

Disposal Options (Additional fees may apply) *

Comments (Max : 50 characters)

Kansas State University