Clinical Studies Archive - Midwestern University Animal Health Institute

Veterinarian / Agency Information

Clinic Resource First Name *

Clinic Resource Last Name *

Suffix

Agency / Clinic Name *

Veterinarian Email Address

Clinic Email Address *

Clinic Phone Number *

Clinic Fax Number

Clinic Address *

Clinic Address

Owner Information

Owner First Name *

Owner Last Name *

Owner Phone Number *

Owner Email Address

Owner Address *

Owner Address

City

State/Province

Zip/Postal

Clinical History

Clinical History *

Euthanized? *

No

Yes, include routeYes, include route

Death Information *

Date / Time of DeathDate / Time of Death

Or, Last Time Known AliveOr, Last Time Known Alive

Travel outside the U.S.? *

No

Yes

Has this animal bitten anyone in the last 90 days? *

No

Yes

Vaccinations, including rabies are up to date. *

No

Yes

Special Requests?

Animal Information

Animal's Name *

Animal ID

Microchip #

Date of Birth

Sex *

M

CM

F

SF

Weight *

Species *

Breed

Color / Markings

Body Disposal

Body Disposal *

Group Cremation
(Ashes NOT returned)

Private Cremation
(Ashes returned to referring vet)

General Body Disposal

Authorization

Reports are generally issued within 10 business days; however, if specialized testing is required this may take longer.
Submitting veterinarian/agency is responsible for cost of services provided and will be invoiced.
It is the responsibility of the submitting veterinarian to deliver results to the animal owners.
ONLY the Veterinarian/Agency will be sent the final report.
Owners will never be contacted in legal investigations.

Authorization *

I confirm that the owner/agent has given consent for their animal to undergo a full postmortem exam (necropsy). I confirm that the owner/agent has given consent for the animal or tissues to be made available for research and educational purposes. I understand the submitting veterinarian/agency is responsible for all fees associated with this submission.

Authorized Printed Name *

Date Authorized

Legal Investigators

Is this a legal case? *

Yes

No

Investigating Police Department

Case Number

Officer / Detective

Phone Number

Email Address

A copy of your submission will be emailed to you. Please print and include when arriving for exam.

Clinical Studies

Clinic & Referral Details

Client Information

Patient Information

Patient Medical Background

Medication History

Veterinarian / Agency Information

Owner Information

Clinical History

Animal Information

Body Disposal

Authorization

Legal Investigators

Veterinarian / Agency Information

Owner Information

Animal Information

Medical Information

Sample Specs