Referring veterinarian’s details

Name of the facility*

Name of the veterinarian*

Phone number*

Email address*

Date of sample collection*

Basic information

Owner’s name*

Patient’s name*

Species*

Age*

Breed*

Sex*

Material for examination*

What other material?

Clinical suspicion / cytological diagnosis*

General symptoms*

Laboratory test results*

lymphocytosismonocytosispresence of atypical cells in peripheral blooderythropenianeutropeniathrombocytopeniahyperglobulinemiahypercalcemianoneother

Lymph node enlargement*

Indicate the enlarged lymph nodes:* poplitealmandibularprescapularmesentericmediastinalgeneralized lymphadenopathyother

Describe*

Please attach the patient’s current cytology results and/or fresh cytological slides related to the material submitted for cytometric analysis.

Referring veterinarian’s details

Basic information

Clinical suspicion / cytological diagnosis*

General symptoms*

Laboratory test results*

Lymph node enlargement*

Hepatomegaly*

Splenomegaly*

Findings on imaging (X-ray / ultrasound / MRI)*

Suspected or past infectious/vector-borne diseases*

Treatment administered

Current test results to attach:

Additional information

Cytometry – Examination questionnaire

Please attach the patient’s current cytology results and/or fresh cytological slides related to the material submitted for cytometric analysis.

Referring veterinarian’s details

Basic information

Clinical suspicion / cytological diagnosis*

General symptoms*

Laboratory test results*

Lymph node enlargement*

Hepatomegaly*

Splenomegaly*

Findings on imaging (X-ray / ultrasound / MRI)*

Suspected or past infectious/vector-borne diseases*

Treatment administered

Current test results to attach:

Additional information