VH Diagnostic – Laboratory Submission | NC State Veterinary Medicine

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Please use this VH Diagnostic – Laboratory Submission form to submit your request

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Veterinarian Contact Information

Submitting Veterinarian - First and Last Name *

Submitting Clinic/Hospital *

Clinic Phone Number and / or Alternate Contact Number *

Clinic Address Street *

State *

City *

Zip / Post Code *

Clinic Fax Number

Clinic Email

Sample Type *

Sample Collection Date *

Sample Collection Time *

Shipment Date *

Owner Contact Information

Patient/Pet Name *

Owners Name (First and Last Name) *

Species *

Dog
Cat

Patient Breed *

Patient Age *

Patient Sex *

Unknown
Female Intact
Male Intact
Female Spayed
Male Cterated

Brief History *

Laboratory *

CLIN MICRO
CLIN VIRO
CLIN PATH/HISTOLOGY

Current Antimicrobial Therapy

Date of Last Current Antimicrobial Therapy (if known)

Sample Collection Method

Vaccine History

Lesion Description

1060 William Moore Drive
Raleigh, NC 27607

919.513.6461

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