Submission Form – Cytology

Dokumentennr.:
2.1-163
Änderungsdatum:
29.01.16
Clinical Pathology
University of Veterinary Medicine Vienna
Department for Pathobiology
1210 Vienna, Veterinärplatz 1
Phone: +431 250 77 5110; Fax: +431 250 77 5196
[email protected]
Seite
1/2
Version
1.0
Submission Form – Cytology
Please complete all obligatory boxes*)!
*)Submitting
person
Animal
*)Species
Date
Signature
*)Sample
O Blood
O Plasma
O Serum
O Urine
O Liquor
*)Report
O Faeces
O Slides
O Effusion ...................................
O Other .......................................
O Dog O Cat O Horse O Cattle O Domestic animal
O Other ...........................................................................
Breed ...............................................................................................
Name ........................................................ Age ..............................
Sex
O Male
O Female
O Castrated
Owner
*)First
name .......................................................................................
name .......................................................................................
*)Date of birth ....................................................................................
*)Address ...........................................................................................
...........................................................................................
*)Zip code, City ..................................................................................
*)Phone number ................................................................................
*)E-Mail ..............................................................................................
*)Last
sent by
O Post
O E-mail ............................................................................
Invoice sent by
O Post
O E-mail: ...........................................................................
*)For
direct invoicing with the owner:
I hereby declare that the fees accrued in Clinical Pathology
will be charged to me.
Signature ..........................................................................................
History (Diagnosis, Treatment):
Cytology
O Cytology
€ 25,00 O CSF
(4-6 Slides/site)
O Effusion (Abdomen, Thorax, Pericard)
(Cell count, cytology, TP, LDH)
O Synovia
(Cell count, Cytology, Mucin, Gluc, TP)
€ 35,00
(cell count, if necessary cytology, pH, Blood,
€ 35,00
Pandy, Nonne Appelt, Osmolality, Gluc, TP)
O Bone Marrow
€ 35,00
€ 35,00
O Lymph Node
O TBS/BAL
€ 35,00
€ 25,00
Dokumentennr.:
2.1-163
Änderungsdatum:
29.01.16
Seite
2/2
Version
1.0
Biopsy
Specimen:
O FNAB
O Imprint
O Swab
Location: ……………………………………………………………………………………….
……………………………………………………………………………………………………
Number of Slides:
Gross appearance:
Size Ø:
O <0.5cm O 0.5-2cm
Consistency:
O soft
O elastic
Surface:
O smooth O uneven
Demarcation:
Fixed to skin:
Fixed to subcutaneous tissue:
Pain:
Growth rate:
O
O
O
O
O
O
O
O
>2cm
solid
hairless
good
yes
yes
yes
rapid
O
O
O
O
O
O
O
hard
O fluctuating
reddened O ulcerated
bad
no
no
no
slow
O non
VENTRAL
DORSAL
Figure applies to all animal species
Special Analysis (only after advance notice by telephone)
O Flow Cytometry Dog (cat, horse)
€ 80,00
Sample
O FNA lymph. tissue (in PBS-Genta)
O PCR for Antigen receptor rearrangement (PARR)
€ 80,00
dog/cat; Slides (stained/unstained NOT covered)
O EDTA-whole blood
O Bone Marrow in EDTA-tube
O Effusion
O PARR of Paraffin-embedded tissues
Dog/cat; Histo-Slides
€ 90,00
O DNA-Extract
O Slides (ONLY PARR)
O Request for Eppendorf tubes
Eppendorf tubes with PBS-Genta can be provided for the submission of FNA lymphatic tissue.
ATTENTION! Sample material for flow cytometry must be received within 24 hours of collection and kept at 4°C.
Samples must be submitted before 12am.