Oregon State University Veterinary Diagnostic Laboratory
For VDL Use
Only
Biopsy/Necropsy Submission Form
Phone: 541-737-3261 Fax: 541-737-6817
Address:
134 Magruder Hall
Email: vet.diagnostic@oregonstate.edu
Corvallis OR 97331-4801
Website:
VDL Account #
Owner Information – (if other than submitter)
Owner:
Submitter:
Address:
Address:
City:
State
Zip
City:
State
Zip
Phone:
Fax:
Phone:
Fax:
Email:
Previous Accessions:
Reporting: E-mail Report
Fax Report
Mail Report
Copy Results To:
Submitting Veterinarian:
Email/Fax:
ANIMAL IDENTIFICATION—Use Multiple Animal ID Form if necessary
SEX: F=Female, FS=Spayed Female, M=Male, MC=Castrated Male, U=Unknown—AGE: Y=Years, M=Months, W=Weeks, D=Days; DOB=Date of Birth
NO.
NAME/IDENTIFIER NO.
SPECIES
BREED
SEX
AGE/DOB
1
2
3
Specimens Submitted - indicate number of each sample type
Date Specimens Taken_____________ Date Specimens Submitted_____________
#___Whole Animal
#____Blood, whole
#___Milk
#___Fluid (origin)
#___Fresh Tissue
#____Serum
#___Urine
#___Swab (origin)
___voided___catheterized
#___Fixed Tissue
#____Plasma
#___Other (origin)
___cystocentesis
___Histopathology on Biopsy (source):_______________________
Necropsy Only: Gross necropsy includes an external examina on of the animal and an examina on
of the internal organs including those of the respiratory system, diges ve system, cardiovascular
___Necropsy Only
system, urogenital system, endocrine system and brain. The spinal cord and peripheral nerves may
also be examined if indicated by the animal’s history.
___Necropsy with Histology
Necropsy with Histology: Gross necropsy along with microscopic examina on of organ ssues.
___Necropsy & Complete Diagnos c Work Up
Necropsy & Complete Diagnos c Work Up: Gross necropsy is performed, with ancillary tes ng
being completed at the discre on of the pathologist.
___Other:_______________________________________________
History: Please include clinical presentation, feed/husbandry changes, onset and duration of illness, treatments (include antibiotics), vaccinations.
Number of animals in this submission______ Total number of animals______ Number of sick animals______ Number of dead animals_______
Date of death____/____/____ Euthanized: Yes______ No______ Rabies Suspect: Yes______ No______
Care of Remains (small animals only):
Post necropsy, remains will only be released to a licensed crematory service. Arrangements must be
made directly with the crematory service, prior to delivery to the OSU VDL. **If no selection is made, routine disposal will be completed**
Routine Disposal
Cremation (specify company)_______________________________
VDL USE ONLY
SHIPPING
COLD PACK
SPECIMEN CONDITION
Date Received:____________
____Courier
___Hand Delivered
___Yes
___No
___No ID on Samples
Rec’d By:_________________
____FedEx
___US Mail
___Frozen
___Sample is leaking
Overnight/Weekend:_______
____Greyhound
UPS: PP Next 2nd
___Thawed
___Other__________________________
BUS.F-15.001, Effective: Page 1 of 1