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Rabies Antibody Titer for Export Animals ­ FAVN ­ OIE

Send to: Rabies Laboratory Kansas State Veterinary Diagnostic Laboratory 1800 Denison Avenue, Mosier Hall Rm O-245 Manhattan, Kansas 66506-5600 Tel. (785) 532-4483/4455 Fax (785) 532-4474/4522 Web www.vet.k-state.edu/rabies

LAB No._____________

*OFFICIAL FORM: Results will be reported on this form. Please TYPE or complete online and then print. Once submitted, information on this form will not be altered. Handwritten information is open to interpretation by this laboratory. Required fields are underlined. *

DESTINATION of ANIMAL BEING EXPORTED: __HAWAII__ __________________________ From: (This address will be used for billing and results and is responsible for all fees incurred.) Submitting Clinic: _____________________________________________ Date: ___________________ Name of Veterinarian: ________________________________________ Phone: ____________________ Mailing Address: ____________________________________________ FAX: ____________________ City: ___________________________ State/Country: ____ /_________________ Zip Code: _________ Name of Owner: _______________________________________________________________________ Street Address: ________________________________________________________________________ City: ___________________________ State/Country: ____ /_________________ Zip Code: _________ Name of Animal: _________________________________ Microchip No.________________________ Species/Breed: ___________________________ Date of Birth: MM-DD-YYYY _______________ Sex: ____________ Color and Unique Markings: _____________________________________________________________ Rabies Vaccination History: __________________________________________ Route: ____________ Serum Draw Date: MM-DD-YYYY _____________________________________________________________________ Signature of Veterinarian: ________________________________________ Date: MM-DD-YYYY _________________

Veterinarian signing form acknowledges identity of pet and confirms microchip identification.

Results of Test:

(For Lab Use Only)

Opened by: ________ Processed by: _________ Computer Entry: _________ Reviewed by: _________ **Must include microchip of animal as well as export destination** Version 07/26/2007

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Request For FAVN-OIE Testing

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