Submission Form - Veterinary Diagnostic Laboratory - University of ...

Phone: (612) 625-8787Fax:(612) 624-8707Toll Free: 1-800-605-8787Necropsy and Sample Submission FormContact Information - Owner/ProducerOwner NameAddressCityPhoneEmailAnimal Location: SiteCountyDelivered ByAttending VeterinarianVeterinarianClinicAddressStateFaxZipHospital/Reference No.StateCity State ZipPhoneEmailResult Reporting and BillingAffiliate (list codes)PhoneEmailBill: Vet/ClinicOtherMajor clinical sign(s)Clinical DiagnosisFaxFaxNarrative history/necropsy findingsSpecimen HistorySpecimen(s)Animal name/IDSpeciesIdent/colorAgeWeightE-mail:vdl@umn.eduWeb site access/results:www.vdl.umn.eduBreed(Please circle: day wk mo yr )(Please circle: lb kg )Gender: M F N/M S/F For Lab Use OnlySample /Specimen Arrived:Date of DeathTime of DeathLive Rm Temp Frozen Cold PkEuthanized:Herd/Flock SizeNo. sickDuration in herd/flockType of housing/environmentRationVaccinationTherapyYesNoPurchased: Yes NoHowNo. in affected groupNo. deadDuration of problem in submitted animal(s)DateFixed OtherAnimal disposal weightSwine Specific Information:Site/FarmPrem./Ref. IDSourceFlowCounty*Please check all applicable choices ifPRRS sequencing is desiredReason for submission:Outbreak SurveillanceClinical signs:Respiratory ReproductiveOtherSeverity of clinical signs:Low Moderate AcuteVaccination:None Autologous KilledIngelvac MLV Ingelvac ATPCremation Request:(Please sign the Permission on page 4.)MassFor officeuse only(No remains returned)Individual(Remains returned. Arranged by Owneror Veterinary Clinic.)VMC Delivery RecordStaff Name (Please print):Note: The MVDL reserves the right to subcontract any work required to complete testing of any and all submissions. Any subcontractedwork will be identified on the laboratory report.DateTimeSYS.FORM.060, Rev. 4, 05/22/2012(Please continue on next page)Page 1

Veterinary Diagnostic Laboratory - University of MinnesotaNecropsy and Sample Submission FormSpecimens for Surgical Pathology1. Location2. Size and shape3. Color, texture and presence of capsule4. Growth pattern (expansion, invasion, pedunculation, etc.)5. Duration Rate of Growth6. Evidence of hemorrhage, necrosis or suppurationIndicate skin lesion site on above drawing7. 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 RETURNEDAs owner or agent of the animal(s) presented for this case, I authorize the Veterinary Diagnostic Laboratory (VDL) staff to proceed as follows:General Laboratory InvestigationParasitologyNecropsy/General Exam of Tissue (includes bacteriology, EM, histopathology,molecular diagnostics, nutrition, parasitology, serology, toxicology, and virology) on upto 2 mammals or 6 poultry with the same clinical problem.Bacteriology/MycologyAerobic CultureAnaerobic CultureClinical ChemistryBile AcidsLarge Animal ProfileOtherCSF ChemistryCKOtherUrine:Fungal Culture SusceptibilityPhenobarbitalSmall Animal ProfileGlucose ProteinComplete Urinalysis Urine protein/Creatinine ratioOtherCytologyCSF (cell counts & cytology)Cytology - tissuesCytology - urine sedimentFluid analysis, completeSourceSourceElectron MicroscopyCell / Tissue ultrastructureViral IdentificationEndocrinology (please use specific endocrinology form)HematologyCryptosporidiumOccult heartwormFecal flotationParasite identificationGiardiaQuantitative Fecal ExamOtherPathology - Histopathology/SurgicalsRoutine H&ESpecial StainsPathology - ImmunohistochemistryImmunological Markers Tissue MarkersInfectious AgentsBone marrow core & aspirate Complete Blood Count (CBC)VirologyBuffy coat smears Differential onlyRBC parasite screen Virus isolation - virus name(s)Coagulation profilePlatelet countReticulocyte count MiscellaneousOtherNote: 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.eduSYS.FORM.060, Rev. 4, 05/22//2012OtherRabies (please use Minnesota Department of Health Rabies form)Serology (Canine)Borrelia burgdorferi-Lyme disease (IFA)Brucella canis (card agglutination test)Brucella canis (tube agglutination test)Canine distemperOtherCanine influenza (HI)Canine parvovirus (HI)Leptospirosis, 6 serovars (MA)Toxoplasma gondii (LA)ToxicologyAnticoagulant ScreenToxic ElementsLeadTrace Nutrient ElementsMycotoxin ScreenOtherFor a detailed list of elements included in each panel, please visit our website:www.vdl.umn.edu/ourservices/toxicologyPage 3

PERMISSION FOR EUTHANASIA, NECROPSY AND DISPOSAL OF REMAINSOwner/Agent (print name): _________________________________________________Animal ID/Name/Species: _________________________________________________Submitting Vet/Clinic/Investigator: ___________________________________________The decision to proceed with euthanasia, necropsy or cremation is an important one. Please consultwith the diagnostician about the following options. Please be aware that ashes can be returned by thecremation service that you select , but remains or other materials from or with the animal (e.g. collar,ID tags, hair from animal, etc.) cannot be returned once received by the VDL (see #4 below).As owner or agent of the animal(s) present for this case, I authorize the Veterinary DiagnosticLaboratory (VDL) staff to proceed as follows:Place Label HereDate:___________________________Pathologist:_____________________Case Number:___________________1. _____ Euthanasia: I authorize the VDL to euthanize/kill the animal(s) using humane,approved procedures.(for SDI/Research only) DATE OF SCHEDULED EUTHANASIA: ________________2. Necropsy (autopsy):a._____ I authorize the VDL to complete a necropsy and to allow the examination to be used for teaching and diagnostic purposes withinthe College of Veterinary Medicine.b. _____ I decline the option of necropsy.3. Research:a._____ I authorize the use of my animal(s) to enhance research programs. Research investigators will frequently learn moreabout disease processes by utilizing blood or tissue samples from affected animals. I consent to the collection of post mortem samples inorder to contribute to future improvements in animal or human health.b. _____I decline the option to use my animal(s) for research purposes.4. Disposition of animal remains:a._____ I authorize the VDL to dispose of the remains using MASS cremation. I understand the remains/ashes cannot be returned to me.b. _____ I assume responsibility for selecting and arranging INDIVIDUAL cremation of the remains of the animal(s). I understand that thecremation service will return the ashes to my vet clinic or to me according to the agreement I make with them. I understand that I have 5business days to provide the VDL with the information needed to submit the animal for individual cremation to the outside provider of mychoice or it will be mass cremated.c. _____I understand that if I do not make a cremation decision today, the VDL will hold small animal remains (dog, cat and other smallspecies) for 5 business days. Large companion animal remains will not be held unless specific arrangements are made with VDLpersonnel. If I do not provide specific instructions, the animal remains will be disposed of using MASS cremation (ashes will not bereturned to the owner/agent).5. Rabies Testing:a._____ This is NOT a rabies examination. I certify that to the best of my knowledge, the above animal(s) has/haveNOT bitten a person or another animal in the past 10 days and the animal(s) has/have NOT been exposed to rabies.b. _____This is a rabies examination. I understand that if the animal is confirmed positive for rabies by Minnesota Department of Health,INDIVIDUAL cremation will NOT be allowed due to risk of exposure. If the rabies status cannot be determined by testing due to anunsatisfactory sample, release of remains for individual cremation will be decided on a case by case basis.6. Fees: The costs of euthanasia and necropsy have been explained to me. I understand these costs will be added to my account, and by affixingmy signature, I accept responsibility for payment of my account in full.OWNER/AGENT: Signature ______________________________________ Date _____________ATTENDING VDL STAFF: Print name _____________________________________ Date ______________SYS.FORM.060, Rev. 4, 05/22//2012Page 4