Research Number Generator Research FormVeterinary Diagnostic form Name* First Last Email* Client ID number*Research NumberNameThis field is for validation purposes and should be left unchanged.Δ "*" indicates required fields Step 1 of 7 - Customer Information14%Name First Last Client ID Number*PhoneEmail Research Number***You will need a new one for each submissionEnter PO numberPlease request a quote if you bill with PO and update the PO in your client portal on receiptRush Case? RUSH THIS CASE!Desired Return Shipping*Fedex OvernightFedex First OvernightFedex 2 dayIf you are using Fedex be sure we have your fedex account information otherwise your samples may be delayedWhat sample type are you sending?* Tissue cassettes whole tissue in jars Tissue blocks-ready to cut Slides OnlyHow many samples are you sending?*Please list tissue type & SpeciesDoes your sample require Decalcification? Yes noThis is for bone samples to be softened.Hematoxylin and Eosin StainingDetail any desired steps or special thickness in the special instructions.I would like H&E sections* Yes NoHow many slides per block?Unstained slidesI would like unstained sections* Yes NoHow many slides per block?Special StainsI would like additional stains Yes NoPlease select your desired stains Trichrome Brown and Brenn Oil Red O Safranin O Picro Sirius Red Periodic Acid Schiffs Giemsa Acid Fast Cementum Annuli custom requestDont see the stain you want?List the stain you are interested in and we will get in touch with you on it.Do you need slide scanning? Yes NoThis is charged at $5 per slideAre you including a usb storage device? Yes NoWould you like us to hold your blocks for future slide cutting? Yes NoAre you including a slide box for return slides? Yes NoWould you like pathology scoring or a quote for pathology? Yes NoIs this for an ongoing pathology project that we are scoring? Yes NoScope of ProjectPlease describe what type of reporting you would like for these samples. Would you like qualatative analysis, semi-quantitative, etc? The more detail on what you would like and about the scope of your project the more accurate quote you will receive.Special InstructionsIf there is anything you would like us to know or do for this submission please detail it here.Upload filesYou can upload images for embedding, batch sheets or papers you are referencing here. If you think it will be helpful feel free to upload it.Max. file size: 256 MB.Δ Clinic InformationClinic Name* First Email* **This is where the results will be sent! Please add info@nationwidehistology.com to your address book and check your spam folder if you don't receive a copy of your submission. If you have not received your results within the specified time frame please give us a call.Phone*Patient InformationPatient NameSpeciesBreedweightAge of the animalTime specimen was placed in formalinCondition suspectedType of Specimen submitted*If your specimen is not in formalin please call asap so we can pick it up right awayLevel ONE Tissue SubmissionsResults within 2-3 days (decal may affect turn around) *Price includes full report and any special stain if needed. Immunohistochemistry or additional special stains will be an additional charge and quoted prior to completion. Biopsy <5cm or 3 punches Biopsy >5cm or 5 punches Additional punches $15 Field necropsy up to 5 organs $80 Additional necropsy tissue $20 per tissueNecropsy requestNecropsies over 30 lbs will be performed within the requested clinic and no disposal will be provided. Please contact us prior to placing your order to check scheduling. Gross and Histopath <30 lbs Gross and Histopath 30-50 lbs Gross and Histopath 50+ lbsCase HistoryPlease provide as much information as possible. If this is a re-submission provide previous accession number in the field below. Feel free to take pictures of written text with a cell phone and attach below.Previous accession number*may not applySubmit additional informationAny helpful photos or drawings can be uploaded here. Photos of written text are also acceptable. Drop files here or Select filesMax. file size: 256 MB. Accession NumberEmailThis field is for validation purposes and should be left unchanged.Δ
