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Companion Animal Clinic
5715 W. Utopia Road
Glendale, Arizona 85308
623.806.7387 (PETS)
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Large Animal Clinic
5725 W. Utopia Road
Glendale, Arizona 85308
623.806.7575
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Diagnostic Pathology Center
5725 W. Utopia Road
Glendale, Arizona 85308
623.806.7540
Directions
Anatomic Pathology Residency Program

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Referral Form

rDVM Referral

Clinic & Referral Details

Which service(s) are you referring? *

Internal Medicine

Surgery

Neurology

Physical Therapy

Referring DVM *

Clinic Name *

Clinic Phone Number *

Clinic Email Address

Preferred Contact Method *

Phone

Email

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

UA

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

Sending

Necropsy Request Form

Necropsy Submission

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

Clinic Address

Clinic Address

Clinic Address

Clinic Address

Clinic Address

Owner Information

Owner First Name *

Owner Last Name *

Owner Phone Number *

Owner Email Address

Owner Address *

Owner Address

Owner Address

Owner Address

City

City

State/Province

State/Province

Zip/Postal

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.

If you are human, leave this field blank.

Sending

Biopsy Request Form

Biopsy Request

Veterinarian / Agency Information

Clinic Resource First Name *

Clinic Resource Last Name *

Suffix

Are you a new client? *

Yes

No

Agency / Clinic Name *

Clinic Phone Number *

Clinic Email Address *

Clinic Address *

Clinic Address

Clinic Address

Clinic Address

Clinic Address

Clinic Address

Clinic Address

Owner Information

Owner First Name *

Owner Last Name *

Owner Phone Number *

Owner Email Address

Owner Address *

Owner Address

Owner Address

Owner Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Animal Information

Animal's Name *

Animal ID

Microchip #

Date of Birth *

Sex *

M

CM

F

SF

Weight *

Species *

Breed

Color / Markings

Medical Information

History / Clinical Features *

Same Details *

10% Formalin

OtherOther

Previous Biopsy *

No

Yes, include dateYes, include date

Ventral Biopsy Site

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Dorsal Biopsy Site

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

Ventral Biopsy Diagram

Dorsal Biopsy Diagram

Sample Specs

Jar # *

Type *

Excisional

Punch

Needle

Sample Site *

Tissue Type *

Sending