DATE PURCHASE ORDER / PROFORMA INVOICE NO. BILL TO INVOICE INFORMATION Company Name:

Company Name: Address

Investigator/Contact City, State, Zip:

Address: Billing Contact Name: Phone:

City, State, Zip: Email Address:

PHONE NUMBER FAX NUMBER CARD TYPE

CREDIT CARD NUMBER Exp. Date

MM/YY

EMAIL SPECIES SPECIMEN TYPE

SERUM BLOOD-EDTA TISSUE OTHER

ANIMAL IDENTIFICATION: (Please attach additional sheets if more space is needed for animal identifications)

NOTE: Place (X) in box by desired test(s), do not circle test(s) doing so may cause incorrect testing to be performed

Primate PCR 8574 ABO phenotyping 8500 B virus 8573 Burkholderia pseudomallei 8554 Campylobacter screen (genus-specific) 8556 Campylobacter jejuni 8579 Chikungunya virus 8501 CMV (Cytomegalovirus) 8541 CMV in African green monkey (SA6) 8539 EMCV (Encephalomyocarditis virus) 8567 Filovirus 8561 Helicobacter screen (genus-specific) 8520 Hepatitis B genotype A-H 8548 Hepatitis B genotype D 8538 Klebsiella pneumoniae rmpA/magA genotyping 8549 Lymphocryptovirus 8534 Malaria 8566 Male Sex 8535 Mamu-A*01 screen 8536 Mamu-A*01 sequencing confirmation 8582 Measles 8587 MRSA (Methicillin-Resistant Staphylococcus aureus) 8527 Mycobacterium (genus-specific) screen 8529 Mycobacterium tuberculosis complex (MTC) 8530 M. tuberculosis and M. bovis 8555 Respiratory syncytial virus (RSV) 8550 Salmonella 8551 Shigella 8531 Salmonella/Shigella 8504 SFV (Simian foamy virus) - African green monkey 8505 SFV - Baboon 8506 SFV- Chimpanzee 8507 SFV - Macaque 8508 SIV (Simian immunodeficiency virus)- African green monkey, AGM-3 8510 SIV - Chimpanzee 8509 SIV - Macaque 8559 SIV screen (genus-specific) 8092 Simian Parvovirus (SPV)

Primate PCR - continued 8511 SRV/D screen (SRV-1, 2, 3, 4, 5) 8512 SRV-1 (SRV/D subtype 1) 8513 SRV-2 (SRV/D subtype 2) 8514 SRV-3 (SRV/D subtype 3) 8553 SRV-4 (SRV/D subtype 4) 8515 SRV-5 (SRV/D subtype 5)

8516 STLV-1 8517 SV40

8552 Simian varicella virus (SVV)

8540 Trypanosoma cruzi nDNA

8583 Trypanosoma cruzi kDNA

8558 Yersinia (genus-specific) screen

8543 Yersinia enterocolitica

8542 Yersinia pseudotuberculosis

8577 Yersinia pseudotuberculosis genotyping

8581 Zika virus

Other PCR test agent ___________________ Primate Microbiology 400 Aerobic Culture 397 Aerobic Sensitivity 401 Anaerobic Culture 396 Anaerobic Sensitivity 5002 Campylobacter 2406 Concentrated Fecal Float 3406 Concentrated Fecal Float (Helminths Only) 2065 E.coli 0157:H7 504 Klebsiella 506 Klebsiella pneumonia 516 Klebsiella pneumonia permucoviscosity phenotype (HMV) 515 Methicillin-resistant Staphylococcus aureus (MRSA) 500 Salmonella 501 Shigella 406 Stool Ova & Parasite Exam 5004 Vibrio 5003 Yersinia

Primate Microbiology Panels 402 Stool Culture - #1 •Salmonella, Shigella, Campylobacter, Vibrio, Yersinia 409 Stool Culture - #2 •Salmonella, Shigella, Campylobacter, Klebsiella 502 Stool Culture - #3 •Salmonella, Shigella 503 Stool Culture - #4 •Salmonella, Shigella, Campylobacter 505 Stool Culture - #5 •Salmonella, Shigella, Yersinia 508 Stool Culture - #6 •Salmonella, Shigella, Campylobacter, Yersinia 509 Stool Culture - #7 •Salmonella, Shigella, Klebsiella 513 Stool Culture - #8 •Salmonella, Shigella, Campylobacter, Yersinia, Klebsiella 514 Stool Culture - #9 •Salmonella, Campylobacter, Klebsiella 517 Stool Culture - #10 •Salmonella, Shigella, Campylobacter, HMV Klebsiella pneumonia

VRL.SA PCR.MICRO Requisition – 05.08.2018 SG (word)

PCR & MICRO Requisition – VRL- San Antonio --- www.vrl.net Submit Samples to: 7540 Louis Pasteur Dr., Suite 250 -- San Antonio, TX 78229 Remit Payment to: P.O. Box 40100 -- San Antonio, Texas 78229 Laboratory: 210-615-7275 (Opt. 1) Billing: 210-615-7275 (Opt. 2) Fax: 210-615-7771