Case Submission Form

Client Data

Client code:

Referring veterinarian:

Institution:

Phone:

E-mail:

Study code*:

Urgent:

Postmortem Priority: 1 (preliminary diagnosis or final report), 2 (preliminary diagnosis or final report) or 3

Patient Data

Species:

Age:

Sex:

Name/ID:

Patient tutor:

Date of cytology/biopsy/death:

Euthanasia (yes or no):	Method:

Anamnesis and case history:

Postmortem examination findings:

Clinical presumptive diagnosis:

Comments:

Shipping address (post mail):

Carles Juan-Sallés

Arquitecto Santiago Pérez Aracil 30 bajo

(CV La Marina Exóticos)

03203 Elche

SPAIN

(*) Study Codes

01a- Cytology (stained)

01b- Cytology (unstained)

02- Biopsy without description

03- Biopsy with description

04- Histopathology of necropsy tissues without description

05- Histopathology of necropsy tissues with description