UNIVERSITY OF GLASGOW SCHOOL OF VETERINARY MEDICINE

POSTMORTEM SUBMISSION FORM

Type of Case:

DIAGNOSTIC

TEACHING

(Please tick)

(TO BE CHARGED)

(GROSS PM ONLY - NO HISTOLOGY, NO CHARGE)

Date of
Submission:

Pathology No:
Animal Name/Identification or Hospital Case No:
Species:

Breed:

Gender:

Number in
group:

Number
Sick:

Number
Dead:

Age:

Name & Address

of Vet Surgeon to
report to:
Name & Address
of Referring Vet
(if applicable):
Owners Name:
Euthanased

Died

Private Cremation

*Legal or Insurance Case:

Yes

No

Neurological Exam requested:

Yes

No

Yes

*Please note legal or insurance cases will incur an extra charge

History: (include clinical signs, duration, significant lab results, vaccinations, treatments etc.)

Clinical Diagnosis:

I certify that I have the legal right to authorise a post mortem examination on this animal.
I understand that this animal may be used for teaching or investigative purposes.
Signature:
Print Name:

No

Date: