necropsy request form - diagnostic laboratories · necropsy request form ... cosmetic necropsy...
TRANSCRIPT
UF Submitter
and phone:
Necropsy Request Form
352-294-4726 Fax: 352-392-1769 http://labs.vetmed.ufl.edu
MR #:
Owner:
Address: Case #:
Clinician to contact for more information:
Phone: Clinician phone number:
Animal Name:
Clinic:
Species: Address:
Breed: City:
Sex: State: ZIP:
Color: Email: Fax:
DOB/age: Date of death:
Manner of Death (check one)
Spontaneous Time (a.m./p.m.):
Euthanasia Agent: Route:
SPECIAL REQUESTS (Check as necessary) Cosmetic Necropsy (contact pathologist first)
Insurance Necropsy Report (complete line below) Cremation (submit additional form)
Insurance Co: Phone No.:
Insurance Co. Address: Insurance
Agent
Zoonotic Disease(s) Suspect? Yes No If yes, which? Microbiology Performed? Yes No Weight: Client to pay UF Hospital death CLINICAL SUMMARY (Include clinical signs, duration of illness, laboratory data, medications, and other pertinent information.) THIS CLINICAL SUMMARY WILL BE PRINTED VERBATIM ON THE REPORT.
CLINICAL DIAGNOSIS:
Permission granted by owner for necropsy and/or disposal of body, and I approve the clinical summary as written:
Signature of Attending Veterinarian PRINT Last Name – IMPORTANT