DR EMILY LANE
BVSC, MPHIL, MRCVS, DIPLOMATE, AMERICAN COLLEGE OF VETERINARY PATHOLOGISTS
SPECIALIST WILD AND DOMESTIC ANIMAL PATHOLOGIST
072 297 6571
emily.lane@hixnet.co.za
(012) 342 3362
www.kbraunweb.com/emilylane
SPECIMEN INFORMATION SHEET
Deliver to: Pathology Section, Faculty of Veterinary Science, P/Bag X04, 1 Soutpan Rd, Onderstepoort 0110
SUBMITTER DETAILS:
NAME: ......................................................................................................... GPS coordinates………………….
POSTAL ADDRESS: ..........................................................................................................................................
CONTACT DETAILS: Phone ................................................... Fax ..................................................................
Cellphone ........................................... Email address: ................................................
I understand that payment of services rendered remains my responsibility and agree that I shall be liable for all attorney fees, collection charges
and interest should I fail to settle any amounts due.
SIGNATURE
.............................................................
DATE .............................................
ANIMAL DETAILS: (include as much information as possible)
BREED……………………………………………. ESTIMATED AGE…………………… SEX ...................
BODY CONDITION: ..........................................................................................................................................
ANIMAL ID: .................................................... DATE OF DEATH ...................................................................
ANY ILLNESS NOTED PRIOR TO DEATH / SUSPECTED DIAGNOSES ...................................................
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ABNORMALITIES NOTED DURING NECROPSY ........................................................................................
skin ......................................................................................................................................................................
lung ......................................................................................................................................................................
heart .....................................................................................................................................................................
liver ......................................................................................................................................................................
spleen ...................................................................................................................................................................
kidney ..................................................................................................................................................................
adrenal .................................................................................................................................................................
gastrointestinal tract .............................................................................................................................................
intestine ................................................................................................................................................................
testis/ovary ...........................................................................................................................................................
brain .....................................................................................................................................................................
bone/marrow ........................................................................................................................................................
joint ......................................................................................................................................................................
lymph node ..........................................................................................................................................................
tongue ..................................................................................................................................................................
trachea ..................................................................................................................................................................
salivary gland .......................................................................................................................................................
thymus .................................................................................................................................................................
Note that carcasses, tissues and agents isolated from samples become the property of the Dr E. Lane
unless other arrangements are made in writing at the time of submission.