Clinical Pathology Request Form Veterinarian: ______Billing: ☐ Veterinarian ☐ Owner Clinic:______Address ______Phone #: ______City______State______Zip______
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FedEx/UPS/DHL: CSU Diagnostic Lab JAMES. L VOSS Clinical Pathology contacts: 300 West Drake Road, DMC 123 VETERINARY TEACHING HOSPITAL Phone: 970-297-1290 Fort Collins, Colorado 80526 COLORADO STATE UNIVERSISTY Fax: 970-297-4441 Diagnostic Lab Phone: 970-297-1281 Email: [email protected] Forms and test info available at: www.dlab.colostate.edu, For PARR or FLOW use Clinical Immunology Form Clinical Pathology Request Form Veterinarian: ______________________________________________________ Billing: ☐ Veterinarian ☐ Owner Clinic:______________________________________________________________ Address _______________________________________________________ Phone #: ______________________________________ City_____________________________ State_______ Zip___________ Send Results to: Fax: _______________________________ and/or Email: _________________________________________________________________________ If desired: rDVM: _________________________________________ Phone #: _____________________________ Fax or Email:_____________________________________________________ Owner: _________________________ Patient: _______________________ Species________ Breed:_______________ DOB: _______________ Sex: ________ DATE COLLECTED (required): __________________________________ ☐ STAT (life or death-$ fee applies) Case History (and/or attach pertinent medical records): CYTOPATHOLOGY ☐ Cytology Number of Sites:________ Site/Source(s): ☐Lymph Node(s) ___________________________________________☐Skin Mass(es) _________________________________________ ☐Liver ☐Spleen ☐Stomach ☐Pancreas ☐Small Intestine ☐Colon ☐Intra-Abdominal Mass: ___________________________ ☐Intra-Thoracic Mass: ______________________________ ☐Lung ☐Other_______________________________________________________ ☐ Fluid, Cytology Only: ☐BAL ☐Bronch. Brush ☐TTW ☐Bile ☐Cyst/Mass ☐Synovial ☐Other________________________ ☐ Fluid Analysis (includes cytology, cell count, differential if applicable, and protein. Select chemistry values also available upon request.) ☐Abdominal ☐Thoracic ☐Coelomic ☐Pericardial ☐CSF: Cisternal / Lumbar ☐Synovial: ____________________ ☐ Bone Marrow Include available CBC data w/ graphs. Includes CBC/Retic if concurrent EDTA blood submitted w/ blood film. ☐ Blood Film Review By a pathologist *Please provide a copy of CBC and instrument printouts ☐ Immunocytochemistry (ICC) Site: _________________________________ HEMATOLOGY (EDTA Whole Blood) ☐ CBC (Includes manual differential) Please send fresh blood smears with the blood tube ☐ Canine or Feline-incl. retic. ☐ Large Animal Mammalian-incl. Fibrinogen est. ☐ Small Animal Mammalian ☐ Avian/Reptile ☐ Platelet Count ☐Reticulocyte Count ☐Fibrinogen Only (estimate) BIOCHEMISTRY (serum or lithium heparin plasma) URINE: Collection Method:_______________ Diagnostic Profiles: ☐Urinalysis ☐Urine Protein-Creatinine Ratio ☐Small Animal Panel ☐Avian/Reptile Panel *Call for other available urine chemistry tests ☐Equine Panel ☐Food Animal Panel IMMUNOHEMATOLOGY (EDTA whole blood) Individual(s): Choose up to 5 of the following ☐ Blood Type, Canine DEA 1 ☐ ALB ☐ BUN ☐ GGT ☐ SDH ☐ TCO2 ☐ ☐ ALP ☐ CA ☐ GLU ☐ TBIL ☐ Uric Acid Blood Type, Feline A/B ☐ AMY ☐ CHOL ☐ IRON ☐ TP ☐ LYTES ☐ Coombs Test ☐ AST ☐ CK ☐ MG ☐ TRIG (Na, K, Cl) ☐ Emergency Foal IgG Snap Test (EDTA Whole Blood, ☐ ALT ☐ CREAT (Creatinine) ☐ PHOS serum, or heparinized plasma. During non-business hours- call first) Select ALB and TP for Globulins COAGULATION (citrate tube/plasma) ☐ Bile Acids ☐ Fasted ☐ Post-prandial Must be received with-in 30 min if not spun. Otherwise, please spin the tube for ☐ Fructosamine 10-12 min in centrifuge and send the plasma in a plain tube (appropriately labeled as cit. plasma). Freeze plasma if shipping the sample. Refrigeration is fine ☐ Ethylene Glycol ☐ Serum ☐ Urine for same day drop-off. ☐ Ionized Calcium Panel: incl. Na+, K+, Cl-, HCO3-, AnGap, ☐ PT ☐ w/INR ☐ PT/a PTT/Fib iCa2+, corrected iCa – Lithium Heparin whole blood or plasma ☐ aPTT ☐ PT/aPTT/Plt collected anaerobically. See website for details. ☐ PT/aPTT ☐ PT/aPTT/Fib/AT (Feline & ☐ FDP* Livestock) ☐ Protein Electrophoresis ☐ Serum ☐ Urine ☐ D-Dimer (DD)** ☐ PT/aPTT/DD**/AT ☐ Routine Immunofixation Add-On* ☐ Serum ☐ Urine ☐ Anti-thrombin (AT) ☐ PT/aPTT/Fib/DD**/AT ☐ Free Light Chain Immunofix. Add-On*☐ Serum ☐ Urine * FDP avail. in dogs only ☐ Fibrinogen (measured) * * D-Dimer avail. in dogs and horses only *Must be ordered in addition to Protein Electrophoresis Some additional tests offered on a case by case basis, please call for details. .