Label Biopsy Request Form

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Rev. 12/16/2016
BIOPSY REQUEST FORM
NEW ACCOUNT
MADISON
For Laboratory Use Only
445 Easterday Lane
Madison, WI 53706
 Fixed
 Unfixed
Phone: (800) 608-8387
FAX: (608) 504-2594
LABEL
BARRON
1521 E. Guy Avenue
E-mail: info@wvdl.wisc.edu
Barron, WI 54812-0097
Phone: (800) 771-8387
FAX: (715) 449-5052
* Required field
OWNER* ________________________________
VETERINARIAN* ______________________________
Address* _________________________________
License No.* ____________________________________
City* ____________________________________
Clinic* _________________________________________
State* ___________________ Zip ___________
Clinic Acct. No. __________________________________
Premise ID _______________________________
Address* _______________________________________
_________________________________________
City* __________________ State* ___ Zip ________
Clinic Premise ID ________________________________
Date samples taken* ________________________
E-MAIL* ______________________________________
Date samples shipped* ______________________
FAX* ______________
Phone* __________________
____________________________________________________________
SUBMITTING VETERINARIAN’S SIGNATURE*
(Signature indicates that specimen(s) were collected by or under the supervision of the signing veterinarian.)
Animal ID / Name: ____________________
Species: _________________
Breed: ___________________
Age (yr/mo.): ________________________
Sex:
F
/ FS
/
M
/ MN
Swabs / other tissues submitted: Y / N
Describe: _____________________________________________
Organ(s) / Tissue(s) _____________________________________________________________________________
______________________________________________________________________________________
Biopsy type:
Entire lesion
Excisional
Number of containers submitted:
_____
Total number of specimens submitted:
______
History _________________________________
____________________________________
____________________________________
____________________________________
VENTRAL
DORSAL
____________________________________
LAB USE ONLY
____________________________________
No. Containers _________
Container ID ___________________
____________________________________
Spec. Container _________
___________
_______________
____________________________________
___________________
___________
_______________
____________________________________
No. blocks / slides _______
Comments _______________________________________________
____________________________________
_______________________________________________________
(Use back if more space needed.)
Initials _________________
Date ___________________

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