QA/HS/ADM/F_001                                                Version 04
                                                                                                             Faculty of Veterinary Science
                         SERVICES RENDERED FOR THE DIAGNOSIS OF HELMINTH AND
                                        GASTROINTESTINAL PROTOZOAL INFECTIONS 
                                                           SUBMISSION FORM
          Helminthology Laboratory
          Department of Veterinary Tropical Diseases                                                         Lab Number:
          Fax: (012) 529-8516
           Technolog        Tel: (012) 529 8383 E-mail:                           Tel: (012) 529 8028 E-
           ists:            louis.taljaard@up.ac.za                               mail:magie.matlala@up.ac.za
           Subject Specialist: Dr. E.V. SCHWAN                          Tel: (012) 529 8099 E-mail: volker.schwan@up.ac.za
                                                           REFERRING VETERINARIAN 
                NB: All the information requested is required to prevent delays in testing and the reporting of results according to Quality
                                                                   Assurance standards. 
           Title:            Initials:       Surname:                                  Practice Name/UP Department:      
           Prof./Dr.                                                                     
           Postal Address:                                                                                                        Postal code:
           Tel:                           Cell:                         Email:                                  Date:
           Fax:                                                                                                 Signature:
           Is your business registered on the University of Pretoria’s financial system?
           (If Yes, please complete the information below.  If No, a debtor registration form will be                                 Yes     No
           forwarded by the laboratory)
           UP Customer Account No:                             Trading as:
           Please Take Note: Diagnostic testing will not be performed unless your UP debtors account 
           number is supplied
                               Title:          Initials:           Surname:
           Owner 
           details:            OVAH Owner Number: (if applicable)………………………………..
                               Farm name: (If 
                               applicable)............................................................................................................................
                               ........................
                               Other: ...................................................................................................................................
                               ................................................
            SERVICES RENDERED FOR THE DIAGNOSIS OF HELMINTH AND GIT PROTOZOAL INFECTIONS  
                                               Select the test(s) required by ticking the appropriate block(s) 
            Code                   Diagnostic Services                     Tic       Code               Diagnostic Services                   Tick
                                                                            k
           H009       Identification of entire/parts of helminths (MORE             H006      Faecal examination: Lungworm infections 
                      prevalent species)                                                      (e.g. Dictyocaulus)
           H010       Identification of entire/parts of helminths (LESS             H019      Faecal examination: Spirocerca lupi infection
                      prevalent species) + Helminth specimens                                 of dogs
                      requiring staining and special mounting 
                      procedures for identification
           H0XX       Identification of measles (cysticerci) and other               H007     Faecal examination: Tapeworm 
                      larval cestodes found in carcasses                                      (Anoplocephala) infections of horses
           H001       Faecal examination: Direct (simple) faecal                    H008      Perianal tape swab examination: Pinworm 
                      flotation (qualitative)                                                 (Oxyuris equi) infection of horses
           H005       Faecal examination: Trematode (fluke) infections              H020      Faecal examination: Cryptosporidium 
                      (Fasciola, Calicophoron, Gastrodiscus,                                  infections
                      Schistosoma) (qualitative)
           H002       Faecal examination: Nematode egg counts                        H021     Faecal examination: Giardia infections
                      (quantitative – McMaster)
           H0YY       Faecal examination: Nematode egg counts and                    H018     Trichinella screening of muscle samples 
                      oocyst counts                                                           obtained from carcasses
           H003       Faecal examination: Faecal cultures with 
                      identification of strongylid nematode larvae 
                                                              SAMPLE INFORMATION
             Species                Breed                 Identification          Sex      Ag Qty              Specimen                 Date
                                                       (Name/ Tag/ OVHA                     e       .                                collected
                                                        Patient Number)
                                                                                                                Issued:  May 2017
     QA/HS/ADM/F_001                        Version 04
                                                           Faculty of Veterinary Science
                     Case History (If available) / Additional Information
                                                       Issued:  May 2017