Phone: (612) 625-8787 E-mail: [email protected] Fax: (612) 624-8707 Web site access/results: Toll Free: 1-800-605-8787 www.vdl.umn.edu Necropsy and Sample Submission Form Contact Information - Owner/Producer Specimen History Owner Name Specimen(s) Address For office use only Animal name/ID City State Phone Fax Zip Ident/color Email Animal Location: Site County Breed Species State Hospital/Reference No. Delivered By Age (Please circle: day wk mo yr ) Weight Gender: (Please circle: lb Date of Death Attending Veterinarian S/F N/M F M kg ) Time of Death Yes No How Veterinarian Euthanized: Clinic Herd/Flock Size No. in affected group Address No. sick No. dead City State Phone Fax Email Result Reporting and Billing Fax Email Bill: Other Live Rm Temp Cold Pk Swine Specific Information: Duration in herd/flock Prem./Ref. ID Type of housing/environment Source Flow County Vaccination Purchased: Frozen Fixed Other Animal disposal weight Site/Farm Therapy Vet/Clinic Sample /Specimen Arrived: Duration of problem in submitted animal(s) Ration Affiliate (list codes) Phone Zip For Lab Use Only Yes No Date Major clinical sign(s) *Please check all applicable choices if PRRS sequencing is desired Reason for submission: Outbreak Surveillance Clinical signs: Respiratory Other Reproductive Severity of clinical signs: Clinical Diagnosis Low Moderate Acute Vaccination: Autologous Killed None Ingelvac MLV Ingelvac ATP Narrative history/necropsy findings Cremation Request: (Please sign the Permission on page 4.) Mass (No remains returned) Individual (Remains returned. Arranged by Owner or Veterinary Clinic.) VMC Delivery Record Staff Name (Please print): Note: The MVDL reserves the right to subcontract any work required to complete testing of any and all submissions. Any subcontracted work will be identified on the laboratory report. SYS.FORM.060, Rev. 9, 5/22/2013 (Please continue on next page) Date Time Page 1 Narrative history/necropsy findings (continued) Section below is for Laboratory use only. Specimen Fixed Specimen condition: Unfixed Live Good Fair Poor Unsuitable Necropsy/Gross findings: SYS.FORM.060, Rev.9, 5/22/2013 Page 2 Veterinary Diagnostic Laboratory - University of Minnesota Necropsy and Sample Submission Form Specimens for Surgical Pathology 1. Location 2. Size and shape 3. Color, texture and presence of capsule 4. Growth pattern (expansion, invasion, pedunculation, etc.) 5. Duration Rate of Growth 6. Evidence of hemorrhage, necrosis or suppuration 7. Indicate skin lesion site on above drawing History of recurrence? Previous Case no. Laboratory Procedures Requested (Please see current fee schedule for complete listing of services available) *I UNDERSTAND THAT THE NON-CREMATED REMAINS CANNOT BE RETURNED. See page 4 "Permission for euthanasia, necropsy & disposal of remains" for further information. As 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 Investigation Parasitology Necropsy/General Exam of Tissue (includes bacteriology, EM, histopathology, molecular diagnostics, nutrition, parasitology, serology, toxicology, and virology). *General Fecal exam for Companion animals includes: aerobic culture (Salmonella), anaerobic culture, Campylobacter culture, electron microscopy, fecal float and Cryptosporidium/Giardia by IFA. Bacteriology/Mycology Aerobic Culture Anaerobic Culture Susceptibility Fungal Culture Clinical Chemistry Phenobarbital Large Animal Profile Parasite identification Giardia Quantitative Fecal Exam General Fecal exam * Other Pathology - Histopathology/Surgicals Routine H&E Special Stains Small Animal Profile Immunological Markers Tissue Markers Infectious Agents Other Other Rabies (please use Minnesota Department of Health Rabies form) CSF Chemistry Glucose Serology (Canine) Protein Other Urine: Complete Urinalysis Other Occult heartworm Fecal flotation Pathology - Immunohistochemistry Bile Acids CK Cryptosporidium Urine protein/Creatinine ratio Cytology Borrelia burgdorferi-Lyme disease (IFA) Canine influenza (HI) Brucella canis (card agglutination test) Canine parvovirus (HI) Brucella canis (tube agglutination test) Leptospirosis, 6 serovars (MA) Canine distemper Other Toxoplasma gondii (LA) Toxicology CSF (cell counts & cytology) Cytology - urine sediment Cytology - tissues Fluid analysis, complete Anticoagulant Screen Toxic Elements Source Source Lead Trace Nutrient Elements Electron Microscopy Mycotoxin Screen Cell / Tissue ultrastructure Viral Identification Other Endocrinology (please use specific endocrinology form) Hematology For a detailed list of elements included in each panel, please visit our website: www.vdl.umn.edu/ourservices/toxicology Bone marrow core & aspirate Complete Blood Count (CBC) Buffy coat smears Differential only RBC parasite screen Coagulation profile Other Platelet count Reticulocyte count Virology Virus isolation - virus name(s) Miscellaneous Note: For supplies, including mailing cartons, contact the lab directly: Phone (612) 625-8787, Fax (612) 624-8707, Toll free 1-800-605-8787, Email [email protected] SYS.FORM.060, Rev. 9, 5/22/2013 Page 3 PERMISSION FOR EUTHANASIA, NECROPSY AND DISPOSAL OF REMAINS Owner/Agent (print name): _________________________________________________ Case Number:___________________ As owner or agent of the animal(s) present for this case, I authorize the Veterinary Diagnostic Laboratory (VDL) staff to proceed as follows: Place Label Here The decision to proceed with euthanasia, necropsy or cremation is an important one. Please consult with the diagnostician about the following options. Please be aware that ashes can be returned by the cremation 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). We do not provide clay paw prints, nor can we allow anyone to make them after the animal is in Necropsy due to our biosafety and biosecurity policies. Pathologist:_____________________ Submitting Vet/Clinic/Investigator: ___________________________________________ Date:___________________________ Animal ID/Name/Species: _________________________________________________ 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 within the 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 more about disease processes by utilizing blood or tissue samples from affected animals. I consent to the collection of post mortem samples in order 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 the cremation 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 5 business days to provide the VDL with the information needed to submit the animal for individual cremation to the outside provider of my choice 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 small species) for 5 business days. Large companion animal remains will not be held unless specific arrangements are made with VDL personnel. If I do not provide specific instructions, the animal remains will be disposed of using MASS cremation (ashes will not be returned 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/have NOT 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 an unsatisfactory 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 affixing my 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. 9, 5/22/2013 Page 4
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