Clone of Cytology Form

Cytology Referral Form
CLINIC’S INFORMATION
Referring Clinic
Phone Number
Email
example@example.com
Fax
Referring Veterinarian
Practice Name
Patient Information
Patient Name
Species
Breed
Sex
Date of Birth

MonthDayYear
Date
Weight
Sample Information
No.of samples submitted
Date of Sampling

MonthDayYear
Date
BumpFlat LesionInternal MassLumpLymph NodeOrganFluidsBALOther
Mention Other
Ultrasound GuidedSquash/CompressionFNA with AspirationFNA w/o AspirationBrushImpressionOthers
Mention Other
Organ/Site:
Regional Lymph Node
YesNo
YesNo
Gross Description
Clinical History
Please verify that you are human*
Should be Empty:

Cytology Referral Form