Hong Kong Mobile Veterinary Ultrasound Service
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HONG KONG MOBILE VETERINARY ULTRASOUND SERVICE
Cytology Request Form
Asia Veterinary Diagnostics Clinical Pathology Team Tel: 2371 0080
Clinic Information
Name
*
Address
*
Phone
*
Fax
*
Requesting DVM
*
Owner and Patient Information
Owner Name
*
Patient Name
*
Species
*
Canine
Feline
Other
Sex
*
MC
FS
Intact Male
Intact Female
Breed& Age
*
History/Clinical Signs/Medical Imaging/Pertinent Laboratory Abnormalities (CBC/Chem/UA):
*
Sample Information
Source 1
*
Number of Slides
*
Method of Collection
*
Date and Time Collected
*
Description of Lesion
*
Source 2
*
Number of Slides
*
Method of Collection
*
Date and Time Collected
*
Description of Lesion
*