Please complete the following CCMS Comparative Pathology Lab - Request for Anatomic Pathology Service Form. The items marked with asterisk (*) are required. Comparative Pathology Lab hours are 9am to 5 pm Mondays through Fridays. We are located in Annenberg 26-92. Necropsies need to be scheduled with the comparative pathologist ahead of time, please call 4-1696 or 4-1498. Samples must be submitted before 3 pm. Please contact Dr. Virginia Gillespie (4-1696) or Ying Dai, lab manager, (4-1498) with questions.

Investigator Info

*PI Name *Fund #
*GCO # *Dept
Phone Fax
*Contact person * Email
*Veterinarian (Diagnostic only)

Animal Information

*Species / ID *Breed / Strain
* Age *Age Units
*Location (Building & room #) *Research / Diagnostic
*Found Dead / Euthanized / Alive If Euthanized, Method of Euthanasia
Date of Death
Origin / Vendor *Is there any risk of exposure to zoonotic or biohazardous agents associated with this submission?
*If Yes, please specify

Sample Info

Clinical History: Clinical presentation (or N/A):

*Clinical History

Experimental History: Experimental manipulations, treatment, transgenes, etc.:

*Experimental History

Description of lesion(s): location, size, color, consistency:

*Description of Lesion(s)

List specific tests

* Image Text: