Cytology Referral Form Get Started Date(Required) MM slash DD slash YYYY Referring Clinic(Required) Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Referring DVM(Required) First Last Referring DVM Email(Required) Client InformationClient Name(Required) First Last Client Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client Email(Required) Client Phone(Required)Pet's Name(Required) Species(Required) Breed(Required) Age(Required) Color(Required) Sex(Required) Intact Male Neutered Male Intact Female Spayed Female Phone(Required)Abdominal/Peritoneal Fluid Abdominal/Peritoneal Fluid Coelomic Tap Abdominal Organ Aspirate Adrenal Gland Bladder Kidney (Right) Kidney (Left) Liver Mass Ovary/Uterus Pancreas Small/Large Intestine Spleen Stomach Other BAL/TTW/ETW Bronchoalveolar Lavage Transtracheal/Endotracheal Wash Blood Smear Review Blood Smear Review Bone Aspirate Bone Aspirate (Bone Aspirate) Location Bone Marrow Bone Marrow (Bone Marrow) Location CSF CSF Joint Tap Joint Tap (Joint Tap) Location Vaginal Vaginal Lymph Node Lymph Node (Lymph Node) Location Nasal Nasal Other Cytology Other Cytology Ocular Ocular Oral Oral Salivary Gland Pericardial Fluid Pericardial Fluid Skin/Subcutaneous Mass Skin/Subcutaneous Mass (Skin/Subcutaneous Mass) Location Smear/Swabs Smear/Swabs Thoracic Aspirate Heart Base Lung Mediastinum Other Thoracic Fluid Thoracic Fluid Urine Sediment (Dry Mount) Urine Sediment (Dry Mount) Urogenital Bladder Ovary/Uterus Prepuce Prostate Testicle Urethra Vagina (not reproductive) When was sample collected?(Required) Additional Info/NotesAdditional History/BloodworkMax. file size: 256 MB.
