Document 6540152

Veterinary Laboratory Services
Submission Form
www.liv.ac.uk/vetpathology
Veterinary Pathology Diagnostic Services, University of Liverpool, Leahurst, Chester High Road, Neston CH64 7TE
Email: [email protected]
Tel. 0151-795-6294
Fax: 0151-795-6295
Animal details/Patient sticker:
Please indicate sample type submitted:
Owner ........................... Animal name ...........................
Species ............................................... Age ....................
Breed .................................................... Sex ....................
Hospital no.................. Previous Path. Lab. No.................
Vet. Surgeon.......................................................................
Practice name ............................................................................
Phone ..................................Fax .......................................
□ Swab*
□ CSF
□ Synovial fluid
□ Tracheal wash
□ Faeces
□ BAL
□ Tissue* (fixed)
□ Guttural Pouch Wash
□ Tissue* (fresh)
□ Blood
□ Skin/plucked hairs
□ Abdominal fluid
□ Urine:
□ Other *
□Catch □Catheter □Cysto
*State/Site ________________________________________
Date of sampling:_ _________________________________
Clinical signs and history (including treatment)
Differential/Presumptive Diagnosis
Histopathology
(please see verso)
Skin
Microbiology
General:
□ Routine BACT. examination (culture, ID, SENS)
□ AB sensitivity: □ Disc diffusion
□ MIC
□ Fungal culture
□ MRSA screen
□ Mycoplasma culture
□ Bordetella culture
□ Direct smear (ZN stain)
□ Skin BACT. examination (culture, ID, SENS)
□ Fungal culture (general)
□ Dermatophyte (direct microscopy/culture)
□ Skin Paras./Dermatophyte (direct mic/culture)
Faeces
□ Faecal bacteriology (general screen for pathogens+ SENS)
□ Salmonella screen
□ Other - please specify
Parasitology (TEST-A-PET)
See TEST-A-PET price list for full test profile
Blood analysis
Faecal analysis
□ Neospora caninum
□ Toxoplasma gondii
□ Leishmania infantum
□ Screen for worm eggs, coccidiosis, Cryptosporidium, Giardia
□ Lungworm Baermann test
□ Lungworm species identification
Gross specimens/sections/skin scrapings etc.
Other (please specify below):
□ Parasite identification
For laboratory use only:
Split sample:
□ Bacteriology
□ Histopathology (verso)
Lab. no:
□ Parasitology
□ Cytology
Received:
Veterinary Laboratory Services
Submission Form
www.liv.ac.uk/vetpathology
Veterinary Pathology Diagnostic Services, University of Liverpool, Leahurst, Chester High Road, Neston CH64 7TE
Email: [email protected]
Tel. 0151 795 6294
Fax: 0151 795 6295
Histopathology:
□
□
For laboratory use only:
Lab. no:
Received:
Cytology:
□
□
Please indicate lesion location/distribution of lesion(s):
Lesion Distribution -
Please indicate lesion location
VENTRAL
DORSAL
RIGHT
LEFT