Phone: (612) 625-8787 E-mail: vdl@umn.edu Fax: (612) 624-8707 Web site access/results: Toll Free: 1-800-605-8787 www.vdl.umn.edu Necropsy and Sample Submission Form Contact Information - Owner/Producer Specimen History Owner Name Specimen(s) Address Animal name/ID City State Phone Fax Zip Age Animal Location: State Breed Ident/color Email Country Species County Wt Gender Date of Death Hospital/Reference No. Euthanized: Time of Death Yes No How Delivered By Herd/Flock Size No. in affected group Attending Veterinarian No. sick No. dead Duration of problem in submitted animal(s) Veterinarian Address City State Phone Fax Email Zip Sample /Specimen Arrived: Live Rm Temp Fixed Other Cold Pk Animal disposal weight Result Reporting and Billing Phone Type of housing/environment Fax Ration Email Bill: Vaccination Vet/Clinic Other Therapy Purchased: Frozen Affiliate (list codes) Duration in herd/flock Clinic For Lab Use Only Swine Specific Information: Yes No Date Major clinical sign(s) Premise Source Flow County *Please check all applicable choices if PRRS sequencing is desired Clinical Diagnosis Reason for submission: Surveillance Outbreak Clinical signs: Respiratory Other Narrative history/necropsy findings Reproductive Severity of clinical signs: Low Moderate Acute Vaccination: Autologous Killed None Ingelvac MLV Ingelvac ATP Submission form (Rev 04/08) (Please continue on next page) Veterinary Diagnostic Laboratory - University of Minnesota Necropsy and Sample Submission Form Specimens for Surgical Pathology 1. Location 2. Size and shape 3. Color, texture and presence of capsule 4. Growth pattern (expansion, invasion, pedunculation, etc.) 5. Duration Rate of Growth 6. Evidence of hemorrhage, necrosis or suppuration 7. Indicate skin lesion site on above drawing History of recurrence? Previous Case no. Laboratory Procedures Requested (Please see current fee schedule for complete listing of services available) *I UNDERSTAND THE REMAINS CANNOT BE RETURNED As owner or agent of the animal(s) presented for this case, I authorize the Veterinary Diagnostic Laboratory (VDL) staff to proceed as follows: Hematology General Laboratory Investigation Necropsy/General Exam of Tissue (includes bacteriology, histopathology, parasitology, and virology) on up to 2 mammals or 6 poultry with the same clinical problem. Bacteriology/Mycology Aerobic Culture Anaerobic Culture Fungal Culture Bone marrow core & aspirate Differential only Buffy coat smears Platelet count Coagulation profile RBC parasite screen Complete Blood Count (CBC) Reticulocyte count Susceptibility Parasitology Clinical Pathology Clinical Chemistry: Avian Profile Bile Acids Large Animal Profile Small Animal Profile Fecal flotation Parasite identification Pathology Cytology - Source Fluid Analysis: Protein Synovial CSF (cell counts & cytology) Fluid analysis, complete Cytology - tissues Histopathology/Surgicals Cytology - urine sediment Rabies (please use Minnesota Department of Health Rabies form) Urine: Complete Urinalysis Occult heartworm Giardia Phenobarbital CSF Cryptosporidium Urine protein/Creatinine ratio Electron Microscopy Feces Endocrinology (please use specific endocrinology form) Miscellaneous Serology (Canine) Borrelia burgdorferi-Lyme disease (IFA) Brucella canis (card agglutination test) Burcella canis (tube agglutination test) Canine distemper Canine parvovirus (HI) Leptospirosis, 6 serovars (MA) Toxoplasma gondii (Latex agglutination) Toxicology Anticoagulant Screen Mycotoxin Screen Lead Trace Mineral Profile Virology Note: For supplies, including mailing cartons, contact the lab directly: Phone (612) 625-8787, Fax (612) 624-8707, Toll free 1-800-605-8787, Email vdl@umn.edu Virus isolation - virus name(s) Forms available online at www.vdl.umn.edu | Rev. 04/08 This page for Laboratory use Specimen Fixed Unfixed Specimen condition: Necropsy/Gross findings: Live Good Fair Poor Unsuitable