Poultry Health Services Ltd.

, 97 East Lake Ramp NE, Airdrie, AB T4A 0C3 Phone (403) 948-8577; Fax (403) 948-0520

Case #:

Poultry Submission Sheet

Farm Name: Owner Name: E-mail: Address: City: Ph: Postal Code: Fax:

Declaration of Agent I, (agent name)___________________________________ of (company)__________________________________ am acting as agent for the above stated farm (the Owner) who is the owner of the birds being submitted for testing. As agent, I am expressly stating that I have full authorization and authority from the Owner to disclose any information required concerning the Owner, and subsequently, to consent and authorize Poultry Health Services Ltd. to further disclose any information required pursuant to federal or provincial legislation. Agent Contact Info:Office Phone: (___)____________ Cell: (____)_______________ Fax: (___ )________________

Quota owning commercial producer?: t Yes t No Indicate Board: t Chicken Producers t Turkey Producers t Hatching Egg Producers t Egg Producers CHICKEN TURKEY t Broiler t Layer t Broiler Breeder t Layer Breeder t Commercial t Roaster t Pullet Number of Birds in Flock: _______

t Breeder OTHER BIRDS (specify) _________________________ Dead _____ Age: ____ t Days t Weeks t Years Housing: t Cages t Floor Pen t Outside Barn Temp: _______

Total Submitted: ____ Live ____All live submissions must

be received directly by a technician

Where did you buy the birds: ______________________ Vaccinations: t Bronchitis t IBD t H.E. Water source: ________________ # of Affected Birds:

t Coccidiosis

Feed/Supplier: _____________________________________ Mortality to Date: (specify # and %)

HISTORY & DETAILS OF PROBLEM: (Include management changes; treatment given - specify what and for how long. Describe problems, including egg production or shell quality issues).

ADDITIONAL COMMENTS: (will not appear on the submission report)

Please choose one of the following: A) Please do all required testing for a complete diagnosis ____ B) Please contact me for all testing costs above the Post Mortem Charge ____

What question(s) would you like answered? _______________________________________________________ What other problems have occurred with this or previous flocks? ______________________________________ Send Results to: t Owner t Submitter t Hatchery _________________ t Processor________________
Consent to Disclosure If it appears, in the sole and absolute discretion of Poultry Health Services Ltd., that the birds submitted are suffering or may be suffering from a provincially or federally notifiable or reportable disease, or in the event that the birds submitted may be suffering from a disease that Poultry Health Services Ltd., in its sole and absolute discretion, deems should be reported, I agree that in addition to any disclosure required under federal or provincial legislation, Poultry Health Services Ltd. can notify immediately the appropriate Egg or Poultry Marketing Board in order to ensure that an effective Emergency Response Plan is executed, and in doing so, Poultry Health Services Ltd. can disclose to the appropriate Board with any and all information required to effectively execute the Emergency Response Plan.. Disclaimer: Please note that any samples collected by the veterinarian, or additional samples submitted with birds (such as feed, water, feces etc.) if not tested, will be held
up to a maximum of 3 months after the initial case submission, unless stated otherwise. After this time, unless specifically requested in writing, the held samples will be destroyed. A fee will apply for samples requested to be stored beyond this time.

Signature of Submitter: _________________________________ Date Received: ______________________