Neurology - Midwestern University Animal Health Institute

Clinic & Referral Details

Which service(s) are you referring? *

Internal Medicine

Surgery

Oncology

Referring DVM *

Clinic Name *

Clinic Phone Number *

Clinic Email Address

Preferred Contact Method *

Phone

Fax

Client Information

Client's Name *

Client's Phone Number *

Client's Email Address *

Patient Information

Patient's Name *

Species *

Breed *

Age *

Weight (kg) *

Sex *

Male

Female

Patient Medical Background

Reason for Referral *

Medical History or Clinical Findings

Previous Diagnostics

CBC

Chemistry

Valley Fever Titer

Abdominal Ultrasound

Other (Cultures, fluid analysis, etc)Other (Cultures, fluid analysis, etc)

Radiographs (Include views)Radiographs (Include views)

Additional Surgical / Therapeutic / Medical Notes?

Medication History

Drug / Supplement *

Dosage *

Frequency *

Duration of Therapy *

Currently Taking?

Currently Being Taken

Add Another Medication Remove Medication

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? *

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.? *

Yes

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

Yes

Vaccinations, including rabies are up to date. *

Yes

Special Requests?

Animal Information

Animal's Name *

Animal ID

Microchip #

Date of Birth

Sex *

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

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.

Veterinarian / Agency Information

Clinic Resource First Name *

Clinic Resource Last Name *

Suffix

Are you a new client? *

Yes

Agency / Clinic Name *

Clinic Phone Number *

Clinic Email Address *

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

Animal Information

Animal's Name *

Animal ID

Microchip #

Date of Birth *

Sex *

Weight *

Species *

Breed

Color / Markings

Medical Information

History / Clinical Features *

Same Details *

10% Formalin

OtherOther

Previous Biopsy *

Yes, include dateYes, include date

Sample Specs

Jar # *

Type *

Excisional

Punch

Needle

Sample Site *

Tissue Type *

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