Dd Form 2834 - Veterinary Consultation Request

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1. TISSUE IN
VETERINARY CONSULTATION REQUEST
DOCTOR'S
ARMED FORCES INSTITUTE OF PATHOLOGY
OFFICE
(X)
(AFIP use only)
(Read Privacy Act Statement and Instructions on back before completing form. Sign and date on back.)
2. OWNER'S LAST NAME
3. ANIMAL NAME/TATTOO NUMBER
4. PREVIOUS AFIP CASE NUMBER ON
ANIMAL
(If applicable)
5. COMMON NAME
6. DATE OF BIRTH
7. AGE
8. SEX
9. NEUTERED
(Dog, Bird, Rat, etc.)
(YYYMMMDDD)
(X)
YES
NO
10. BREED/TYPE/STRAIN
11. GENUS AND SPECIES
(Beagle, Canary, F-344, etc.)
(Scientific name)
12. MATERIALS FORWARDED
13. CONTRIBUTOR'S CASE IDENTIFICATION
(X or complete as applicable)
a. SURGICAL PATHOLOGY ACCESSION NUMBER(S)
CLINICAL INFORMATION (Required)
SURGICAL PATHOLOGY REPORT (Required)
AUTOPSY REPORT (Required)
PHOTOS, CLINICAL/GROSS
b. AUTOPSY/NECROPSY ACCESSION NUMBER
X-RAYS
SLIDES (Qty) (Required)
BLOCKS (Qty)
c. EUTHANIZED (X)
WET TISSUE
YES
NO
OTHER
14. PRIORITY REQUESTED
(X)
NO LETTER (AFIP use only)
ROUTINE
RUSH
15. CLINICAL HISTORY (Location and size of lesion, signs, duration, physical and laboratory findings.)
16. CONTRIBUTOR'S WORKING DIAGNOSIS (Include legible copy of surgical pathology or autopsy report, if applicable.)
17. COMMENTS AND REQUESTS
18. CONTRIBUTOR
a. NAME (Last, First, Middle Initial) (Include Title, e.g., Dr., CPT, etc.)
b. COMPLETE MAILING ADDRESS
c. TELEPHONE NUMBER (Incl. area code)
d. FAX NUMBER (Incl. area code)
e. E-MAIL ADDRESS
DD FORM 2834, SEP 2002
PREVIOUS EDITION IS OBSOLETE.
LOCAL REPRODUCTION AUTHORIZED
Adobe Professional 7.0
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