Form 1 – Request for determination of rabies antibodies by FAVN

ATTENTION: If you have entered the wrong information, you will not be able to make corrections after sending the request. In case of entering wrong informations, repeat the data entry in the new form.
* Mandatory fieldsPlease fill in the fields marked with (*)

Submitting veterinarian:

Veterinary institution: *

Name and surname: *

Street: *

House or building number: *

Appartment number:

ZIP code: *

City: *

Country:

Phone: *

Fax:

Email: *

Owner’s details:

Name and surname: *

Street: *

House or building number: *

Appartment number:

ZIP code: *

City: *

Country:

Phone:

Fax:

Email:

Address of delivery:

If the delivery address is different from the address of the apartment, please provide the necessary information:

NoYes

Name and surname: *

Street: *

House or building number: *

Appartment number:

ZIP code: *

City: *

Country:

Animal’s details:

Name:

Species: *

Race:

Sex:

Date of birth:

Tattoo number (optional):

Microchip number (usually 15 digits): *

Date of sampling: *

Destination country (optional):

Animal’s vaccinal status:

Total number of rabies vaccine doses received in the life course: *

Date of the last vaccination: *

Proprietary name of the last vaccine received:

By submitting a request for laboratory analysis, you agree that the Institute for Rabies Control - Pasteur Institute collects, processes, and uses your data. The method of data collection and processing is described in the Privacy Policy and the Personal Data Protection Policy, which you can read here. By clicking "Submit," you consent to the use and processing of the personal data you entered into the form.

NOTE: After completing the form, on your e-mail will be sent a copy of the completed form as a PDF file. Print, sign, and authenticate the form, then send it with the sample marked with the number of microchip.