submission form email copy

Animal Health Trust
Lanwades Park, Kentford, Newmarket, Suffolk, CB8 7UU
Registered charity no: 209642
Influenza Surveillance Scheme
Diagnostic Submission Form
EQUIFLUNET.ORG.UK
Disease Information
Attending Vet
Practice
Address
Postcode
Telephone
Fax/Email
Owner Name
Horse Location
County
Postcode
Horse Details
Please ensure you fill in Horse Details and Disease Information for each
horse sampled
Name
Age/DOB
Gender
Mare/filly
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Gelding
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Stallion/colt
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Breed/type
Latest vaccination history:
Date
Vaccine used
Batch No.
1st Vacc 
2nd Vacc 
3rd Vacc 
Annual Booster

Unvaccinated

Sample type submitted
Swab:
Nasal
Clotted blood/serum
Nasopharyngeal


What date was this sample taken
Signs:
Heart rate (RPM)
Respiratory rate (RPM)
Temperature (oC)
Inappetance
Cough
mild
dry harsh
productive
severe
Serous nasal discharge
Mucopurulent nasal discharge
Mucoid nasal discharge
Swollen lymph nodes
Conjunctivitis
Lethargy
Other details
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What date was the illness first recognised?
How many other horses are affected?
Prior to this visit, have other horses from this premises been sampled
in the last 2 weeks by you or another vet?
Yes

No

How many
If you are sampling other horses from this premises today, please
state how many

Vet Signature:..........................................................................................................
Often Equine Influenza transmission is associated with horse movement, to aid diagnosis please fill in the information below. This section
only needs to be filled out once per premises visited.
Horse Movement
Are isolation facilities available?
Yes

No

No. of horses on yard?
No. of in-contacts?
Are new arrivals quarantined?
Yes

No

Have any horses been offsite in the last 2
weeks?
Yes

No

No. of new arrivals within last 2 weeks?
Dates of recent arrivals?
Do horses share tack?
Yes

No

Do horses share other equipment e.g. water
troughs?
Yes

No

Horses kept in (please tick all that apply):
Individual stables

Barn system

Separate grazing

Group grazing
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Other
Premises type (please tick most relevant)
Private premises
Livery
Training/Competition Yard
Stud
Riding School
Other
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Has influenza been diagnosed on the yard
before?
Yes

No

Unknown

If so, how long ago?
All equine influenza testing submitted using this form is free of charge. Additional diagnostic tests can be performed but these will be charged according to the
current published price list. Please indicate which additional tests you would like on a diagnostic laboratory services submission form. The terms and conditions
on which laboratory tests are carried out are available at www.aht.org.uk. Sample submission is acceptance of these terms and conditions.
FOR LAB USE:
Opened by:
Tests assigned by:
Entered by:
F269a/1
Time Received:
Split by:
Bact
Clin Path
Cyto
Histo
Serol
Virol
Research
Please send samples and forms to:
Diagnostic Laboratory Services
Animal Health Trust,
Lanwades Park,
Kentford,
Newmarket,
Suffolk CB8 7UU
THE HORSERACE BETTING LEVY BOARD
Funds the Animal Health Trust’s Equine In�luenza Programme