CADETSMHMASSAY
VETERINARIANCONTACTDETAILS
Nameofveterinarian: / Email: / Phone #Nameofpractice:
Street: / City: / State, ZipCode
OWNERCONTACTDETAILS
Name: / Email: / Phone #Street: / City: / State, ZipCode
PATIENTDETAILS
Nameofdog: / Age: / Breed:Sex: MI MN FI FS / DateofBirth(MM/DD/YR): //20 / AKCRegistration # (ifapplicable)
SAMPLESUBMISSIONINSTRUCTIONS(visit full details)
Clinicalspecimensmaybesubmittedforanalysisinanyofthefollowingformats:
- Cytologicalsmears: provideaminimumoftwoslides. Slidesmustnotbecoverslipped.
- Aspiratedcellsinbufferedsolution:
- Formalin-fixedparaffin-embeddedtissues: provideaminimumoffivethick (25micron) sections, eithermountedonslidesorcurledinasterileplastictube. Entireblocksmayalsobesubmitted, andcanbereturneduponreceiptofasupplementalshippingfee ().
Itiscriticalthatthesubmittedsampleisrepresentativeofthesuspectedtumor. Werecommendsamplingthesuspectedtumormassfrommultipleangles, tomaximizetheabilitytocapturethesuspectedtumor.
Specimens from uptofourindependentanatomicalsitesfromthesamedogmaybesubmittedforanalysis.
Purchase of the CADETSM HM Assay($95) includes analysis of a single site. Additionalsites will bechargedat $50 each.
Please check one box below to confirm the number of independent sites to be tested for the dog named above.
1 site ($95) 2 sites ($ 145) 3 sites ($ 195) 4 sites ($ 245)
Pleasecompletethesampledescriptionsection(s) onthefollowingpages, oneforeachsitetobetested.
Samples cannot be processed in the absence of a fully completed submission form.
IcertifythatIhavecorrectlyidentifiedthedogsampledandthattheinformationcontainedinthisformistrueandaccuratetothebestofmyknowledge. Iamauthorizedtocollectasamplefromtheabovedogandsubmitfortestingforthepresenceofgeneticsignaturesofcaninehistiocyticmalignancy (HM). I understand that purchase of the CADETSMHMAssay includes analysis of a single anatomical site and that I will be billed separately for the cost of testing additional sites from the same dog at $50 per site.
Ihavereviewedtheinformationprovidedat. IrecognizethatinterpretationoftheresultsoftheCADETSMHMAssayisdependentontheprovisionofaclinicalspecimenthatisrepresentativeofthesuspectedneoplasmobserved, andIcertifythatthespecimensuppliedmeetsthesecriteriatothebestofmyknowledge.
MM DD YR
Name:Signature: ______Date://20
CADETSMHMASSAY
- Pleasecompleteonesampledescriptionsectionforeachsitetobetested.
- Mark each clinical specimen clearly with the site to which it corresponds (site 1, site 2 etc).
SITE 1
Anatomicalsitefromwhichthe specimenwasobtained:
Dateonwhichspecimenwasobtained:
Sampletype (checkoneonly):
Cytologicalsmears(minimumoftworepresentativeslides, mustNOTbecoverslipped)
Number of replicate slides submitted
Ifstained, pleaseindicatethestainused
AspiratedcellsinsuspensionPleaseindicatethenatureofanybufferpresente.g. saline
* Formalin-fixedparaffin-embeddedtissuesectionsmountedonslide(mustbeunstained)
* Formalin-fixedparaffin-embeddedtissuesectionscurledintube
* Formalin-fixedparaffin-embeddedtissueblockandmatchedH&Eslide
SITE 2
Anatomicalsitefromwhich the specimenwasobtained:
Dateonwhichspecimenwasobtained:
Sampletype (checkoneonly):
Cytologicalsmears(minimumoftworepresentativeslides, mustNOTbecoverslipped)
Number of replicate slides submitted
Ifstained, pleaseindicatethestainused
AspiratedcellsinsuspensionPleaseindicatethenatureofanybufferpresente.g. saline
* Formalin-fixedparaffin-embeddedtissuesectionsmountedonslide(mustbeunstained)
* Formalin-fixedparaffin-embeddedtissuesectionscurledintube
* Formalin-fixedparaffin-embeddedtissueblockandmatchedH&Eslide
SITE 3
Anatomicalsitefromwhich the specimenwasobtained:
Dateonwhichspecimenwasobtained:
Sampletype (checkoneonly):
Cytologicalsmears(minimumoftworepresentativeslides, mustNOTbecoverslipped)
Number of replicate slides submitted
Ifstained, pleaseindicatethestainused
AspiratedcellsinsuspensionPleaseindicatethenatureofanybufferpresente.g. saline
* Formalin-fixedparaffin-embeddedtissuesectionsmountedonslide(mustbeunstained)
* Formalin-fixedparaffin-embeddedtissuesectionscurledintube
* Formalin-fixedparaffin-embeddedtissueblockandmatchedH&Eslide
SITE 4
Anatomicalsitefromwhich the specimenwasobtained:
Dateonwhichspecimenwasobtained:
Sampletype (checkoneonly):
Cytologicalsmears(minimumoftworepresentativeslides, mustNOTbecoverslipped)
Number of replicate slides submitted
Ifstained, pleaseindicatethestainused
AspiratedcellsinsuspensionPleaseindicatethenatureofanybufferpresente.g. saline
* Formalin-fixedparaffin-embeddedtissuesectionsmountedonslide(mustbeunstained)
* Formalin-fixedparaffin-embeddedtissuesectionscurledintube
* Formalin-fixedparaffin-embeddedtissueblockandmatchedH&Eslide