Form Dl 105 – Fill Out and Use This PDF

The DL 105 form, utilized by the Animal Health Diagnostic Center at the College of Veterinary Medicine, Cornell University, is a crucial document for submitting histopathology samples. This partnership with the NYS Dept of Ag & Markets ensures a streamlined process for the submission and testing of specimens, which may include participation in state or federal surveillance programs. To initiate the submission process for veterinary histopathology testing, click the button below.

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Form Dl 105 PDF Details

The DL 105 form, integral to the operations of the Animal Health Diagnostic Center at Cornell University's College of Veterinary Medicine, serves as a primary medium for submitting histopathology specimens. Crafted in collaboration with the New York State Department of Agriculture & Markets, this form facilitates critical communication between veterinarians and the diagnostic center's pathology experts. Available contact information covers both traditional mail and modern digital communication methods, ensuring accessibility. Urgent submissions are recognized, with a notation for an additional fee, emphasizing the form's adaptability to various case urgencies. The comprehensive format requests detailed information about the submitting owner and veterinarian, along with specifics about the animal involved, including species, breed, and age. To enable a precise diagnosis, it requires an extensive history of the animal's condition, treatment details, and a description of symptoms or lesions. Furthermore, the form indicates that submitted samples become the property of the center, possibly being used in state or federal surveillance programs, underscoring the broader public health implications. Instructions also delineate the requirement for other potentially necessary tests and fees, ensuring that submitting veterinarians understand their responsibilities in the diagnostic process. Overall, the DL 105 form stands as a crucial tool for advancing animal health diagnostics, reflecting a meticulous procedure for collecting, submitting, and analyzing veterinary specimens.

Question	Answer
Form Name	Form Dl 105
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Histopathology_ Submission_Form cornell histopathology form

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Histopathology Submission Form

Animal Health Diagnostic Center

College of Veterinary Medicine, Cornell University		Histopathology Contacts
In Partnership with the NYS Dept of Ag & Markets		Phone: 607-253-3312
US Postal Service Address:	FedEx/UPS Service Address:		(8-4:30, M-F)
		Fax:	607-253-3357
PO Box 5786	240 Farrier Rd
		Web: diagcenter.vet.cornell.edu
Ithaca, NY 14852-5786	Ithaca, NY 14853
		E-mail: diagcenter@cornell.edu

LAB USE ONLY

__________________________________

AHDC Accession No./ Date

__________________________________

Pathology Case Number

PLEASE NOTE: SAMPLES SUBMITTED FOR TESTING BECOME THE PROPERTY OF THE ANIMAL HEALTH DIAGNOSTIC CENTER AND MAY BE

TESTED AS PART OF STATE/FEDERAL SURVEILLANCE PROGRAMS

PLEASE COMPLETE ALL FIELDS, PRINT LEGIBLY, AND TYPE OR USE BLACK INK ONLY

Cornell Acct No. __________  Check if URGENT! (Fee+add'l $60)		Your Internal Case/Reference No.** ______________________________
Submitting		Owner _____________________________________________________
Veterinarian* ________________________________________________		Owner _____________________________________________________
Clinic Name _________________________________________________		Address ____________________________________________________
Address ____________________________________________________		City, State, Zip _______________________________________________
City, State, Zip _______________________________________________		Phone Number ( ________ ) ____________________________________
Phone No. ( ___________ )	___________-_______________________	County ________________________ Town _______________________
Submitting Vet's Signature:	___________________________________	NYS Premises ID ____________________________________________
Add’l instructions:		ATTENTION:

Histopathology specimens are referred to:

Surgical Pathology Service, Pathology Section, Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University

ANIMAL IDENTIFICATION

SEX CODES: M=Male, MR=Mare (equine only), MC=Castrated Male, F=Female, SF=Spayed Female

AGE CODES: Y=Years, M=Months, W=Weeks, D=Days; DOB=Date of Birth

ANIMAL NAME / IDENTIFIER NO.	SPECIES	BREED	SEX	AGE/DOB

HISTOPATHOLOGY	POST MORTEM	DATE SPECIMEN
SUBMISSION TYPE	INTERVAL	TAKEN
Biopsy  Post Mortem 

HISTORY: Clinical history required. Give detailed information regarding affected animal. (NY State Contract pricing may apply; see AHDC Test & Fee Schedule.)

General (Clinical presentation, treatment, etc.)

Description of lesion(s) (Describe location, distribution, size, color, consistency):

Date: onset of illness:

_____________

In animals submitted:

______________

Herd size:________

No. dead:________

No. affected:______

Check here if add’l history is on back or attached.


Clinical Diagnosis:	_________________________________________________________________________________________________________
Tissues Submitted:	_________________________________________________________________________________________________________
Has previous material been submitted for this problem?		YES  NO  UNKNOWN 
If so, enter	Date(s): ____________________________________ Histopathology Nos.: _____________________________________

PLEASE NOTE: SAMPLES SUBMITTED FOR TESTING BECOME THE PROPERTY OF THE ANIMAL HEALTH DIAGNOSTIC CENTER.

*The submitting veterinarian is responsible for the requested tests, fees associated with this submission, and for notifying the owner of test results.

	LAB USE ONLY
NON-CONTRACT  CONTRACT 	No. cassettes prepared: __________	No. tissues prepared: ___________

Additional AHDC testing requested: _______________________________________________________________________________

Special Stains: _______________________________________________________________________________________________

Comments: __________________________________________________________________________________________________

OPENED BY:	 DHL	 Mail	DATE AND	 TISSUES RECEIVED FIXED	 TISSUES RECEIVED UNFIXED
	 FX	 Pri Mail	TIME REC’D: ______________	 UNFIXED TISSUES FIXED ON: Date:		Time:
	 UPS-Grnd	 Exp Mail		 UNFIXED TISSUES FIXED ON: Date:		Time:
	 UPS-Grnd	 Exp Mail
	 UPS-ND		SHIPPED: _____________	Receipt Status of Unfixed Tissue:	 FROZEN	 NOT FROZEN
_________	 Other: __________________			COMMENT:

** If your Internal Reference No. is entered on this form, it will be used to identify this case on the test result form and on the billing statement (max. 17 character field).

DL-105 10/10

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Step 1: Access the PDF file inside our editor by pressing the "Get Form Button" above on this page.

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So as to finalize this PDF form, ensure that you provide the right information in each blank field:

1. First, once filling out the Form Dl 105, start in the area that has the following blank fields:

2. Once your current task is complete, take the next step – fill out all of these fields - SEX CODES MMale MRMare equine only, ANIMAL NAME IDENTIFIER NO, SPECIES BREED SEX AGEDOB, HISTOPATHOLOGY SUBMISSION TYPE, INTERVAL, TAKEN, Biopsy Post Mortem, HISTORY Clinical history required, Description of lesions Describe, Check here if addl history is on, Clinical Diagnosis, Tissues Submitted Has previous, Dates Histopathology Nos, YES NO UNKNOWN, and PLEASE NOTE SAMPLES SUBMITTED FOR with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Form Dl 105 conclusion process described (part 2)

When it comes to Dates Histopathology Nos and SPECIES BREED SEX AGEDOB, be sure that you review things here. Both of these could be the most important ones in the PDF.

3. Completing NONCONTRACT CONTRACT Additional, DATE AND Mail DHL TIME RECD, TISSUES RECEIVED FIXED TISSUES, Time, and If your Internal Reference No is is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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Form Dl 105 – Fill Out and Use This PDF

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