Patient MR# (UF use only): rdvm Clinic, Patient Medical Record#: Case# (UF use only): Owner s Name: Submitter s Full Name (to contact for add l information): Address Agency: City, State, Zip Code: Agency Phone#: Owner s Phone: Address: Patient s Name: City, State, Zip Code Species: Sex: Male Email Address (For Lab Results): Breed N. Male Female DOB/Age: Agency Fax#: S. Female Color: Email Address (For Invoicing, If Different): Unkn./Other Weight: Date Collected: Has tissue from this animal been submitted to UF Diagnostic Laboratories in past: If, what is the Case/Accession#: - Date Sent: General Information Submission of crime scene photos and/or videos?: Sent by email: Submission of radiographs?: Sent via email: Sent by: Fax (which one): Sent by email: If found, microchip #: Death Due to: Euthanasia By Whom: Date of Death: \ \ Time of Death: AM PM Agent/Method: Last Date Animal Seen Alive: \ \ Last Time Animal Seen Alive: Route: AM PM By Whom: After being found, How was body handle/packaged: How was body transported: How was body stored: By Whom: Disposition of Remains (Disposed by Lab unless noted otherwise). Stored by lab Hold for pick up by: Owner Representative (Name): Additional Special Request Charges that may apply: Ancillary Tests (up to $ (at pathologists discretion) Neurologic Exam (Spinal Cord) Postmortem radiographs Postmortem CT Blank copy 1887271. Printed on 9/18/2018 1:33 PM (EDT). Page 1 of 5 Sent by Fax: (which one): Was animal scanned for microchip?: Fax (which one): Death Due to: Natural/Found Dead Date of Death/Found: \ \ Submission of medical records and/or laboratory data?:
Temperature of the body (rectal), prior to refrigeration or freezing: ( F/ C) Insect activity and whether there was collection of entomology samples in the field: If deceased at the scene, what did the animal feel like when found (Check All That Apply): Warm to touch Cool to touch Limp (Flexible) Body condition score: Water available: Food available: Condition of food: Other: Specify, scale utilized: Condition of water: Clean Partially Clean Dirty Fresh Food bowl condition: Type food: Rigid (Stiff) Partially Fresh Clean Partially Clean Commercial Brand Homemade Old Dirty Comments: Enclosure or Restriction: In dog house In Home Kennel Only Kennel w/run Permanent type shelter: Number of animals (by species) within enclosure: Describe: Cleanliness of Environment: Excellent Adequate Poor Comments: Shelter Protection: Adequately protects from sun From rain: Describe Shelter: Blank copy 1887271. Printed on 9/18/2018 1:33 PM (EDT). Page 2 of 5 Chained/Tethered Loose in yard
Animal Medical History Source of Medical History: Owner Veterinarian of Animal Veterinarian (other) Last Visit to Veterinarian: \ \ Name of Veterinarian: Clinic Address: Clinic Phone: Clinic Email: Veterinarian s Email: Was animal injured prior to death: Was animal on any medication: If, how many hours/days prior: If yes, list all medication: Vaccination status: Up to Date Dewormed: If yes, list date: \ \ Type of dewormer: Past Due Never been vaccinated Were any of the following noted in the 72 hours prior to animals death: Fever Lethargy Decreased appetite Vomiting Diarrhea Breathing abnormalities Seizures Has the animal at any point had any of the following: Cyanosis (blue color) Heart abnormalities Abnormal weight gain or loss Metabolic disorders Breathing difficulties Seizures If Clinical Exam Performed Pain during palpation: : Locomotion: Limping rmal Body secretions: Oral Mucosa color: If yes, describe: If yes, describe: Cherry red Hydration status: t ambulatory If limping/not ambulatory, describe: rmal Dark red Pink Pale Dehydrated ( %) rmal Skin irritations: Itchy Scars: If yes, describe & mark on body diagram below: Lesions/Injuries: Dry Hairless areas (describe) Yellow Blue Fur/Coat/Hair: Matted White If yes, describe & mark on body diagram below: Feces normal: If no, describe: Ectoparasites: If no, describe: Were advanced diagnostics performed (if yes, include results): Blank copy 1887271. Printed on 9/18/2018 1:33 PM (EDT). Page 3 of 5 Bloodwork (labs) Radiographs Ultrasound
Animal s Behavior Evidence of abnormal behavior: Evidence of stereotypical behavior: Animal s attitude (alone): Alert If yes, describe: If yes, describe: Apathetic Animal s attitude (w/owner present): Quiet Happy Animal s attitude to human presence: Aggressive Happy Unsure Aggressive Calm Unsure Anxious Calm Anxious Scene Information Location of body at time of discovery: General appearance of incident scene (use diagram below as needed and/or attach clear color pictures): Animals body position at time of discovery: On back Was the animal found alive at the scene: On left side On right side Sternal If yes, describe how animal was behaving: Was resuscitation attempted on animal: If yes, describe what was done to resuscitate the animal: Discoloration of the head or oral mucosa: Discoloration of skin: Bodily fluids present (froth): Marks on body: Abrasions Lacerations Punctures Bruises If yes, describe: Number of animals at the scene (by species): Does preliminary investigation suggest any of the following: Electrocution Trauma Suspicious circumstances Natural death If yes to any of the above, explain here: Blank copy 1887271. Printed on 9/18/2018 1:33 PM (EDT). Page 4 of 5 Asphyxia Environmental hazards (ie: carbon monoxide) Dietary issues (i.e. no food/water) Hypothermia/hyperthermia
Case Summary: If applicable, note location of external abnormalities on diagram. Signature of Submitter PRINT Full Name *UFVH Office Use Only* CHAIN OF CUSTODY DOCUMENTS From Submitter: Shipping Code: USHIP UDROP UCDEL LPCRW$ LPCRWA Samples Rcvd.(tube type & quantity): Fresh Ambient Initials: Ice Packs Dry Ice Leaking Date/Time Stamp: Blank copy 1887271. Printed on 9/18/2018 1:33 PM (EDT). Page 5 of 5 Broken Formalin