Web Portal: https://mvdl.mt.gov Email: mvdl@mt.gov Website: http://liv.mt.gov/Diagnostic-Lab Phone 406-994-4885 Fax 406-994-6344

Lab Use Only: Clear Form

Owner/Submitter: ___ Billing Address: ___ Address: ___

<table><tr><td>Copy of Report To:</td><td>Colony</td><td>Wilcox</td><td>Other:</td><td></td></tr><tr><td></td><td>Fax</td><td>Email</td><td>Other:</td><td></td></tr><tr><td></td><td>Fax/Email/#:</td><td></td><td></td><td></td></tr></table>

Phone: ___ Email: ___

Fax: ___ Other: ___

Ranch/Collection Site: ___

Sample Profile: Chick Papers Pullets Weeks: ___ Pre-Production Weeks: ___ Mid-Production (Layers) Weeks: ___ Push Outs Weeks: ___ Other: ___

Collection Date/Time: ___

Sampled By (please print/type): ___

Sampled By (signature affixed): ___

Number/Type Specimens: ___

Flock ID: _____ House/Barn ID: _____ Copy of Report To: Colony Wilcox Other: _____ Fax Email Other: _____ Fax/Email/#: _____

Test Procedure Requested (choose one): PCR Culture

Sample ID Number: Lab Use Only:

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