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*

Clinic Information