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Veterinary Diagnostic Laboratory

RABIES SUBMISSION FORM

Submitter Last Name
Submitter First Name
Address
City
State
Zip
Phone
Email
ANIMAL LOCATION: Location of Animal or Exposure
Address
City
State
Zip
SAMPLES
Consecutive Sample ID#'s
RABIES VACCINATIONS (CHECK ONE)
DISPOSITION OF REMAINS (REQUIRED)
PATIENT INFORMATION
Species
Breed
# Animal ID
Age
Gender
Weight
Date of Death Cause of Death
Insert 1
Delete
X
Clinical observations/comments:
HUMAN EXPOSURE HISTORY - PROVIDE ALL DATA REQUESTED
Number of potential human exposures

Name of exposed
Address
State
City
Zip
Day Phone
Cell Phone
Date of exposure
Type of exposure
Site of exposure
Additional comments

Physician
Clinic
Address
Physician Phone
Physician FAX
State
City
Zip


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If you are experiencing difficulty or need additional help, please contact the ISU VDL at 515-294-1950.
Veterinary Diagnostic Laboratory
Iowa State University
1937 Christensen Drive, Ames, IA 50011-1100
Phone: 515-294-1950, Fax: 515-294-3564, Email: isuvdl@iastate.edu
v13.16.2