Veterinary Diagnostic Services Order Form

Veterinary Diagnostic Testing Order Form
Sampling

Please ensure that blood samples are collected in the appropriate tube type and that there is ample blood provided or samples cannot be processed. Tube types accepted are listed in the service order for each test below and proper blood collection and storage guidelines can be found at: Zoetis (https://www2.zoetis.com.au/content/_assets/docs/Resource-center/VETSCAN-Blood-Sample-Handling-Guide.pdf)

Getting Samples to the Lab

Samples are received at the lab Monday - Thursday, 10 AM - 6 PM, and Friday, 10 AM - 5 PM. We are closed on Saturday and Sunday and cannot receive samples during the weekend (unless established in specific job contracts).

Samples are collected from the airport in Anchorage on Monday, Wednesday, and Friday each week.

Regulatory biosecurity samples (Avian Influenza and Equine Infectious Anemia) must be delivered by veterinarian or clinic representative or laboratory courier, as to maintain chain of custody. Otherwise, samples may be collected by veterinarians and delivered by owners to decrease turnaround times on STAT labs.

Payment

Cash, check, and credit card (Visa, Mastercard, and Discover) are accepted. Veterinarians may be invoiced per contract.

Receiving Results

With the exception of culture & sensitivity testing and some biosecurity testing, all results may be rushed and returned in less than 2 hours for a $50 rush fee.

Blood chemistries, hematology, fecal analysis, passive immunity (IgG), and Fibrinogen samples received before 2pm will be resulted by 7pm. Samples received after 2pm may be resulted by 10 am the following morning.

For assistance or questions, contact

support@landandseaslab.com

(907) 357-9800

3516 W. Coghlan Circle #3 Wasilla, AK 99623
Submitter & Payer Information

Please indicate who is submitting the samples, who the reporting veterinarian is (if applicable), and who will be paying for the testing.
Submitter Name*
The person responsible for...
Email*
This is where the report will be emailed
Phone Number*
Reporting Veterinarian/Clinic
Reporting Veterinarian/Clinic Email
Reporting Veterinarian/Clinic Phone Number
Please indicate who will be paying for this testing*
Animal Owner Information
Owner Name
Owner Email
example@example.com
Owner Phone Number
Please enter a valid phone number.
Sample Information

Please submit one form per species
Animal(s)*
Species*

HorseCowGoatSheepMooseAvianPigCaribouOther
Sample Type(s)*

BloodUrineStoolMilkSwabOther
Sample Collection Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Sample Condition*

AmbientRefrigeratedFrozenOther
Collection Tube Type(s)

Purple or Lavender TopRed TopGold TopTiger TopBlue TopGreen TopWhite TopOther
Swab Type(s)

Aerobic SwabAnaerobic SwabOther
Other Collection Type(s)

Specimen CupGloveOther
Required Tests

Please indicate which tests you would like performed
Chemistry (Choose only one) - (Gold, red, tiger, and green top tubes accepted. Separated serum may be submitted in white top tubes.)

Panel 1: ALP, ALT, GGT, Chol, BA, Tbil, BUNPanel 2: ALB, ALP, AST, GGT, Glob, CK, TP, BUN, Mg+, Ca+, PhosPanel 3: ALB, ALP, AST, GGT Glob, CK, TP, BUN, Mg+, Ca+, Phos, BA, Chol, Tbil, ALTPanel 4: ALB, ALP, AST, GGT, Glob, Glu, TP, BUN, Cre, Ca+, Na+, K+, Cl-, tCO2, ALT, TbilPanel 5: ALB, ALP, AST, GGT, Glob, Glu, TP, BUN, Cre, Ca+, Na+, K+, Cl-, tCO2, ALT, Tbil, BA, CholPanel 6: ALB, ALP, AST, GGT, Glob, Glu, TP, BUN, Cre, Ca+, Na+, K+, Cl-, tCO2, ALT, Tbil, CK, Mg, PhosPanel 7: ALB, ALP, AST, GGT, Glob, Glu, TP, BUN, Cre, Ca+, Na+, K+, Cl-, tCO2, ALT, Tbil, CK, Mg, Phos, BA, Chol
Hematology (Lavendar or purple top tubes accepted.)

Complete Blood Count w/ Differential
BioSecurity Testing (Gold, red, and tiger-top tubes accepted.)

Avian Influenza (screening, non-regulatory)BluetongueBovine Leukosis Virus (BLV)Bovine Viral Diarrhea (BVD)Caprine Arthritis Encephalitis (CAE)Caseous Lymphadenitis (CL)Coxiella Burnetii (Q Fever)Mycobacterium Avium Paratuberculosis (Johne's)
Microbiology - Culture & Sensitivity

Aerobic culture onlyAerobic ID onlyAerobic ID and antibiotic sensitivityAnaerobic culture onlyAnaerobic ID onlyAnaerobic ID and antibiotic sensitivity
Other Testing

Foal IgG (Passive Immunity) - (Lavendar, purple, gold, red, tiger, and white tubes accepted.)Fibrinogen (Only blue tops accepted.)Fecal Float (Ova & Parasites)
Additional Testing Instructions and Notes
Agreement & Signature
- Results relate solely to the sample received for analysis.
- Uncertainties for numerical values are not factored into decision rules.
- Due to varying volumes of samples submitted, as well as unforeseen issues, Land & Seas Laboratory does not guarantee
  turnaround times.
- All test results will remain private and confidential. The laboratory may not and will not discuss your sample details,
  contract terms, or any tests results with persons not employed by the laboratory other than the veterinarian for which
  authorization has been given on this service agreement above.
- Customers will be informed of any deviation from this contract or need to transfer samples to another facility.
- I agree to pay Land & Seas Laboratory the fees determined above for diagnostic testing to be completed.
I agree that these tests are adequate for the purpose of evaluating the animal(s) from which the samples were taken and that the fees listed will
be paid within 30 days of service.
Signature*

Clear
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Veterinary Diagnostic Testing Order Form

Submitter & Payer Information

Animal Owner Information

Sample Information

Required Tests

Agreement & Signature