FleaNet sample submission form

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Please fill out form for each animal for which you collect and submit fleas. If you have more than a few animals, please contact the FleaNet team for an easier and more efficient method to submit information and fleas: FleaNet@vetmed.wisc.edu

Email *

Name of person filling out the form: *

Date when fleas were collected: *

YYYY

Person that collected the fleas, if different from person filling out the form:

Name of animal: *

Date of Birth *

YYYY

Species *

Breed *

Sex *

Spay/Neuter Status *

Weight (kg) *

Estimate of how many fleas were on the animal *

Estimate of how many fleas were collected *

Any other ectoparasites collected?

Animal owner address *

Animal flea preventative history *

Animal lifestyle (indoor, outdoor, hunting, etc) *

Any other animals that live in the household? *

If you would like us to email you a pre-paid FedEx shipping label, please enter the email address to send to below.

If you do not need a prepaid shipping label, please box and ship fleas to:

Attn: FleaNet @ Lashnits Lab

Room 3376, School of Veterinary Medicine

2015 Linden Dr., Madison WI 53706

For more information on how to pack and ship fleas, see: Shipping SOP.

Thank you for your interest in collecting fleas for FleaNet!

If you have any other comments or questions, please leave them here or email us any time at FleaNet@vetmed.wisc.edu

Thank you!!

Send me a copy of my responses.

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