Necropsy and Sample Submission Form Contact Information - Owner/Producer Specimen History 612) 625-8787

Phone:
(612) 625-8787
E-mail: vdl@umn.edu
Fax:
(612) 624-8707
Web site access/results:
Toll Free: 1-800-605-8787
www.vdl.umn.edu
Necropsy and Sample Submission Form
Contact Information - Owner/Producer
Specimen History
Owner Name
Specimen(s)
Address
For office
use only
Animal name/ID
City
State
Phone
Fax
Zip
Ident/color
Email
Animal Location: Site
County
Breed
Species
State
Hospital/Reference No.
Delivered By
Age
(Please circle: day wk mo yr )
Weight
Gender:
(Please circle: lb
Date of Death
Attending Veterinarian
S/F
N/M
F
M
kg )
Time of Death
Yes
No How
Veterinarian
Euthanized:
Clinic
Herd/Flock Size
No. in affected group
Address
No. sick
No. dead
City
State
Phone
Fax
Email
Result Reporting and Billing
Fax
Email
Bill:
Other
Live
Rm Temp
Cold Pk
Swine Specific Information:
Duration in herd/flock
Prem./Ref. ID
Type of housing/environment
Source
Flow
County
Vaccination
Purchased:
Frozen
Fixed Other
Animal disposal weight
Site/Farm
Therapy
Vet/Clinic
Sample /Specimen Arrived:
Duration of problem in submitted animal(s)
Ration
Affiliate (list codes)
Phone
Zip
For Lab Use Only
Yes
No
Date
Major clinical sign(s)
*Please check all applicable choices if
PRRS sequencing is desired
Reason for submission:
Outbreak
Surveillance
Clinical signs:
Respiratory
Other
Reproductive
Severity of clinical signs:
Clinical Diagnosis
Low
Moderate
Acute
Vaccination:
Autologous
Killed
None
Ingelvac MLV
Ingelvac ATP
Narrative history/necropsy findings
Cremation Request:
(Please sign the Permission on page 4.)
Mass (No remains returned)
Individual
(Remains returned. Arranged by Owner
or Veterinary Clinic.)
VMC Delivery Record
Staff Name (Please print):
Note: The MVDL reserves the right to subcontract any work required to complete testing of any and all submissions. Any subcontracted
work will be identified on the laboratory report.
SYS.FORM.060, Rev. 9, 5/22/2013
(Please continue on next page)
Date
Time
Page 1
Narrative history/necropsy findings (continued)
Section below is for Laboratory use only.
Specimen
Fixed
Specimen condition:
Unfixed
Live
Good
Fair
Poor
Unsuitable
Necropsy/Gross findings:
SYS.FORM.060, Rev.9, 5/22/2013
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Veterinary Diagnostic Laboratory - University of Minnesota
Necropsy and Sample Submission Form
Specimens for Surgical Pathology
1. Location
2. Size and shape
3. Color, texture and presence of capsule
4. Growth pattern (expansion, invasion, pedunculation, etc.)
5. Duration
Rate of Growth
6. Evidence of hemorrhage, necrosis or suppuration
7.
Indicate skin lesion site on above drawing
History of recurrence?
Previous Case no.
Laboratory Procedures Requested (Please see current fee schedule for complete listing of services available)
*I UNDERSTAND THAT THE NON-CREMATED REMAINS CANNOT BE RETURNED. See page 4 "Permission for euthanasia, necropsy & disposal of remains" for further
information.
As owner or agent of the animal(s) presented for this case, I authorize the Veterinary Diagnostic Laboratory (VDL) staff to proceed as follows:
General Laboratory Investigation
Parasitology
Necropsy/General Exam of Tissue (includes bacteriology, EM, histopathology,
molecular diagnostics, nutrition, parasitology, serology, toxicology, and virology).
*General Fecal exam for Companion animals includes: aerobic culture (Salmonella),
anaerobic culture, Campylobacter culture, electron microscopy, fecal float and
Cryptosporidium/Giardia by IFA.
Bacteriology/Mycology
Aerobic Culture
Anaerobic Culture
Susceptibility
Fungal Culture
Clinical Chemistry
Phenobarbital
Large Animal Profile
Parasite identification
Giardia
Quantitative Fecal Exam
General Fecal exam *
Other
Pathology - Histopathology/Surgicals
Routine H&E
Special Stains
Small Animal Profile
Immunological Markers
Tissue Markers
Infectious Agents
Other
Other
Rabies (please use Minnesota Department of Health Rabies form)
CSF Chemistry
Glucose
Serology (Canine)
Protein
Other
Urine:
Complete Urinalysis
Other
Occult heartworm
Fecal flotation
Pathology - Immunohistochemistry
Bile Acids
CK
Cryptosporidium
Urine protein/Creatinine ratio
Cytology
Borrelia burgdorferi-Lyme disease (IFA)
Canine influenza (HI)
Brucella canis (card agglutination test)
Canine parvovirus (HI)
Brucella canis (tube agglutination test)
Leptospirosis, 6 serovars (MA)
Canine distemper
Other
Toxoplasma gondii (LA)
Toxicology
CSF (cell counts & cytology)
Cytology - urine sediment
Cytology - tissues
Fluid analysis, complete
Anticoagulant Screen
Toxic Elements
Source
Source
Lead
Trace Nutrient Elements
Electron Microscopy
Mycotoxin Screen
Cell / Tissue ultrastructure
Viral Identification
Other
Endocrinology (please use specific endocrinology form)
Hematology
For a detailed list of elements included in each panel, please visit our website:
www.vdl.umn.edu/ourservices/toxicology
Bone marrow core & aspirate
Complete Blood Count (CBC)
Buffy coat smears
Differential only
RBC parasite screen
Coagulation profile
Other
Platelet count
Reticulocyte count
Virology
Virus isolation - virus name(s)
Miscellaneous
Note: For supplies, including mailing cartons, contact the lab directly: Phone (612) 625-8787, Fax (612) 624-8707, Toll free 1-800-605-8787, Email vdl@umn.edu
SYS.FORM.060, Rev. 9, 5/22/2013
Page 3
PERMISSION FOR EUTHANASIA, NECROPSY AND DISPOSAL OF REMAINS
Owner/Agent (print name): _________________________________________________
Case Number:___________________
As owner or agent of the animal(s) present for this case, I authorize the Veterinary Diagnostic
Laboratory (VDL) staff to proceed as follows:
Place Label Here
The decision to proceed with euthanasia, necropsy or cremation is an important one. Please consult
with the diagnostician about the following options. Please be aware that ashes can be returned by the
cremation service that you select , but remains or other materials from or with the animal (e.g. collar,
ID tags, hair from animal, etc.) cannot be returned once received by the VDL (see #4 below). We do not
provide clay paw prints, nor can we allow anyone to make them after the animal is in Necropsy due to our
biosafety and biosecurity policies.
Pathologist:_____________________
Submitting Vet/Clinic/Investigator: ___________________________________________
Date:___________________________
Animal ID/Name/Species: _________________________________________________
1. _____ Euthanasia: I authorize the VDL to euthanize/kill the animal(s) using humane,
approved procedures.
(for SDI/Research only) DATE OF SCHEDULED EUTHANASIA: ________________
2. Necropsy (autopsy):
a._____ I authorize the VDL to complete a necropsy and to allow the examination to be used for teaching and diagnostic purposes within
the College of Veterinary Medicine.
b. _____ I decline the option of necropsy.
3. Research:
a._____ I authorize the use of my animal(s) to enhance research programs. Research investigators will frequently learn more
about disease processes by utilizing blood or tissue samples from affected animals. I consent to the collection of post mortem samples in
order to contribute to future improvements in animal or human health.
b. _____I decline the option to use my animal(s) for research purposes.
4. Disposition of animal remains:
a._____ I authorize the VDL to dispose of the remains using MASS cremation. I understand the remains/ashes cannot be returned to me.
b. _____ I assume responsibility for selecting and arranging INDIVIDUAL cremation of the remains of the animal(s). I understand that the
cremation service will return the ashes to my vet clinic or to me according to the agreement I make with them. I understand that I have 5
business days to provide the VDL with the information needed to submit the animal for individual cremation to the outside provider of my
choice or it will be mass cremated.
c. _____I understand that if I do not make a cremation decision today, the VDL will hold small animal remains (dog, cat and other small
species) for 5 business days. Large companion animal remains will not be held unless specific arrangements are made with VDL
personnel. If I do not provide specific instructions, the animal remains will be disposed of using MASS cremation (ashes will not be
returned to the owner/agent).
5. Rabies Testing:
a._____ This is NOT a rabies examination. I certify that to the best of my knowledge, the above animal(s) has/have
NOT bitten a person or another animal in the past 10 days and the animal(s) has/have NOT been exposed to rabies.
b. _____This is a rabies examination. I understand that if the animal is confirmed positive for rabies by Minnesota Department of Health,
INDIVIDUAL cremation will NOT be allowed due to risk of exposure. If the rabies status cannot be determined by testing due to an
unsatisfactory sample, release of remains for individual cremation will be decided on a case by case basis.
6. Fees: The costs of euthanasia and necropsy have been explained to me. I understand these costs will be added to my account, and by affixing
my signature, I accept responsibility for payment of my account in full.
OWNER/AGENT:
Signature ______________________________________
Date _____________
ATTENDING VDL STAFF:
Print name _____________________________________
Date ______________
SYS.FORM.060, Rev. 9, 5/22/2013
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