Transcription of HISTO/CYTOLOGY REQUEST FORM
1 2022 IDEXX Laboratories, Inc. All rights reserved. 2012020-0122-UKIDEXX Reference LaboratoriesHISTO/ cytology REQUEST FORMHISTOLOGY / cytology PROFILESBMEXBone Marrow CytologyHICLH istology & Culture & SensitivitySWCYC ytology & Culture & SensitivityHISMH istology & cytology on SmearsHISKH istology & Complete Skin ExaminationHICYH istology & cytology on FluidsTissues to be submitted in 10% Neutral Buffered Formalin. Polypropylene tubes with fixative are available from the laboratory. Please do not push large tissues into small pots. Please ensure absorbent material is included in order to contain any leakage in handles personal data responsibly and has adopted the privacy policy which can be found at ID / PIMS NUMBER OWNER S NAMENAME OF ANIMALSPECIESAGEBREEDSEXNEUTERED ENTIRELAB NUMBER (LAB USE ONLY)VET CODEDATEVETERINARY SURGEONADDRESS STAMPFOR LAB USE ONLYEDTA FLUIDHISTOLOGYPLAIN URINEGTDPLAIN FLUIDSKIN SCRAPEBORIC URINEREVEDTA URINESKIN SLIDEUNLABELLEDNHSFIXED FLUIDEDTA WHOLE BLOODLOCK BOXFRESH TISSUESMEARCOURIERHISTOLOGY UHIS FastTrack Histology Samples received Monday to Thursday.
2 Excludes tissues requiring decalcification or incompletely fixed specimensNumber of Tissues submitted:Please indicate lesion description and site of tissue(s) below:Site 1 Site 2 Site 3 Additional SitesHas whole tumour been submitted? o Yes o NoBiopsy Method Endoscopy (NOT GI) Excisional Incisional HISTLIV HIST GI Post Mortem HISTSK HISTFPE Other: cytology cytology TypeNumber of Sites submitted:Please indicate lesion description and site of sample(s) below:Site 1 Site 2 Site 3 Additional SitesFluid Tracheal BAL Nasal Prostatic Synovial CSF Urine Abdominal Pleural Pericardial Other please specify.
3 Relevant clinical history required for appropriate interpretation (please indicate Differential Diagnosis / Disease Suspected / Specific questions you would like answered) Please include Previous Reference Number(s) if appropriate Please complete all relevant information on the form for a complete reportFATTYPRE-STAINEDNO DIFFI ncludes Comprehensive Haematology - please submit 1 ml EDTA and air dried smearIDEXX Laboratories Ltd Tel: UK: +44 (0) 2037887508 Eire: +353 (0) 15621211 Fax: 01937 544001 RECEIVED:For a full list of all available test, sample requirements and online ordering please visit INFODoes the animal originate from a country outside the UK (please state country)Y oN o Has the animal recently travelled abroad or been in contact with a non-UK bred animal that has travelled abroadY oN oPlease indicate if the sample has been obtained from a patient receiving chemotherapy or radioactive iodineY oN oWhere: LAB NUMBERCUT DATEINITIALSNUMBER OF TISSUES RECDIAMETER OF TISSUESPM TISSUESDESCRIPTION OF TISSUE: Please circle.
4 LABELLED PICTURE OF SECTIONS TAKENNUMBER OF BLOCKS TAKENALL PROCBATCHPROC DECALSHORT DECALRE-FIX BBFIXATORRE-FIXNUMBER OF DECAL BLOCKS TAKENDECALALL PROCDATE DECALTISSUES BAGGEDFOR LABORATORY USE ONLYY~ 14 DAYSYNN12345 LiverSkin BiopsyIncompletely FixedEndoscopicBiopsyNo Lymph Node Seen (Mammary)SeriallySlicedNo differ-entiationNo Lesion SeenCut in HalfFriableTissueMay Not SurviveProcessingLungLNSpleenHeartKidney Gut:Other:Cut OpenBy VetOther Biopsy.
