Submission form for histological examination of organ and tissue samples
Please complete all relevant fields. The tab key can be used to navigate between fields.
Species:	Breed:	Animal Name:
Date of birth (Age):	Sex:	Microchip no./ear tag and TVD:
Submitting vet (Clinic/practice): Surname, Forename (Veterinarian): Address: Postcode, city: Telephone no.:	Report and bill to be sent to: Veterinarian Report: by E-Mail Email address: Frozen section Call prior to submission: 044 635 85 84 Diagnosis by call at phone no.: Express (formalinfixed) Diagnosis by Email at address: TEM Electronmicroscopy
Owner (Surname, Forename): Address: Postcode, city:
History (including symptoms, duration, treatment, macroscopic findings, ultrasound and radiographic findings):
Organ/Tissue (please state precise location where necessary):
Date of sampling:
Suspected diagnosis/specific questions: Please perform immunohistochemistry (if considered meaningful by pathologist) Suspected tumour: tinging of margins by pathologist
Laboratory investigations:	Results:
Bacteriology
Parasitology
Blood tests
Mycology
Cytology
Therapy:	Previous histological or cytological examination(s):
Previous treatment no yes	Date:	No.:
If yes; duration, drug, response to therapy:	Diagnosis:

Mit Einreichung des vorliegenden Formulars bzw. des Untersuchungsantrags anerkennt der Auftraggeber die Anwendbarkeit der Allgemeinen Geschäftsbedingungen des Instituts für Veterinärpathologie der Universität Zürich (AGB IVPZ), einsehbar unter http://www.vetpathology.uzh.ch/de/Diagnostik.html. Das IVPZ
ist berechtigt, nach Abschluss der Untersuchung noch vorhandenes Untersuchungsmaterial für Forschung und Lehre weiterzuverwenden.