Date_____________________________________
Owner's Name______________________________________ Animal's Name___________________________
Species________________________________ Breed____________________________ Sex________ Age________________
Clinic____________________________________________ Clinician______________________________________________
Address_______________________________________________________________________________________________
Telephone_____________________________ Fax_____________________________
Relevant History (including recent therapy):
Lesion Description/Post Mortem Findings:
# of Tissue Fragments Submitted:____
Histology____ Cytology____
Tissue Types Submitted: ____________________________________________________________________________________
Disease Suspected: ________________________________________________________________________________________
SEND SAMPLES TO: Special Requests or Comments:_____________________
HISTOVET, Dr. Brian Wilcock ________________________________________________
21 Vardon Dr., Guelph, Ontario, N1G 1W8
FOR OFFICE USE ONLY
B___ C___ T___
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Quality Management System
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registered to ISO 9001:2000
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