INFECTIOUS DISEASES LABORATORY 
DEPARTMENT OF MEDICAL MICROBIOLOGY
COLLEGE OF VETERINARY MEDICINE
UNIVERSITY OF GEORGIA
ATHENS, GA 30602-7386
Phone: 706-542-5812              FAX: 706-542-5233

Please complete all information and Print Legibly

NAME:  

For Laboratory Use Only
HOSPITAL:   SUBMISSION #:
ADDRESS:

 

 PHONE: DATE RECEIVED:
CITY: STATE: ZIP:

 

 SECURE FAX: DATE REPORTED:

DNA probe detection for Psittacine Beak & Feather Disease Virus (PBFDV), Avian Polyomavirus (APV), Chlamydia psittaci (CP), Gender Determination (GD)

Please Circle Requested Test(s) for Each Sample

Sample Date

Owner

Bird ID

Species

PBFDV

Result

APV

Result

CP

Result

GD

Result
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  
       

PBFDV

  

APV

  

CP

  

GD

  

REPORTING & PAYMENT

Payment is required with sample submission. In order to keep the prices for the tests as low as possible we will not be able to accept credit cards for payment.  The fees are $12.00 /sample /test; $18.00 for gender determination.

Checks should be made to Infectious Diseases Laboratory. Results will be returned by first class mail or sent to a secure FAX machine, if a FAX number is given. The receiver accepts responsibility for the security of the receiving FAX machine. Please note, we will not phone before sending a FAX.

Fill in information below:

For PO#’s, Name & address if different from above.

CHECK #:

AMOUNT:

PO #:

 

My signature certifies that I have read and understand the instructions given for sample submission. Additionally, I accept that the records of the Infectious Diseases Laboratory of the University of Georgia’s College of Veterinary Medicine are confidential to the extent allowed by the law and the policies of the University of Georgia as defined by the Board of Regents. No results can be given by telephone. In no event shall the Infectious Diseases Laboratory, the personnel of the Infectious Diseases Laboratory, the College of Veterinary Medicine, the University of Georgia, the Board of Regents nor the state of Georgia be liable for incidental, consequential, special or other damages arising from the testing of the sample(s) or the providing of test results.

Veterinarian’s Signature __________________________________________ (Required for Sample Testing)