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Er Name Veterinarian Company Clinic Address For office use only Attending Veterinarian Address Phone City Zip Fax State Phone State City Fax Email Email Animal/Location Zip Result Reporting and Billing Site/Farm Premises/Reference ID Phone For Lab Use Only Affiliate (list codes) Country State Regulatory Premises ID Zip Sample /Specimen Arrived: Live Email County Bill: Species Serology Test Samples: Vet/Clinic Rm Temp Fixed Fax Other F.

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