Form CF.ACC.12 "Biopsy/Dermatopathology Submission Form" - Alabama

What Is Form CF.ACC.12?

This is a legal form that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Alabama Department of Agriculture and Industries;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CF.ACC.12 by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries.

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Download Form CF.ACC.12 "Biopsy/Dermatopathology Submission Form" - Alabama

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Diagnostic Laboratory System 
 
AVDL 
www.labs.alabama.gov 
ACCESSION #: 
 
DATE 
Thompson Bishop Sparks State Diagnostic Lab 
RECEIVED: 
890 Simms Rd 
 
CASE 
Auburn, Al 36832 
 
COORDINATOR: 
Ph: (334) 844‐4987 
 
 
 CHARGE   N/C PAID:              CASH   CHECK #: 
Fx: (334) 844‐7206 
 
 
Auburn Lab  
 
 
Biopsy/Dermatopathology 
Tech Initials
 
 USPS    UPS    FEDEX     OTHER:  
 
Submission Form 
Submitted by:  Veterinarian  Owner  Other: 
 
** ALL submitted samples become the property of TBSSDL. Some testing may be subcontracted or referred out to qualified laboratories. You will be contacted for 
 
permission if this will incur further charges. TBSSDL no longer offers cytology. Please send samples directly to Auburn CVM Clinical Pathology Service. ** 
Veterinarian 
Owner 
Clinic 
County 
Address 
Address 
City                                State                    Zip 
City                                      State                    Zip 
Phone 
Phone                                  Fax 
Fax 
Email 
Email 
Previous Case # 
Report to:  Vet    Own    Other: 
Bill to:  Vet    Own    Other: 
Report Preference:  Email   Fax    Mail 
Bill Preference:  Email   Fax    Mail 
 
 
Specimen:  Fixed Tissue, Single    Fixed Tissue, Multiple    Fresh Tissue, Single    Fresh Tissue, Multiple 
Animal Name/ID 
Species 
Breed 
Sex 
Age 
 
(Lab Use 
 Please Mark All that Apply 
Only) 
* Liver copper levels require submission of fresh (unfixed) liver and incur an additional cost: $10.00) * 
………………… 
 
**Completeness of excision can only be assessed for excisional biopsies (masses submitted whole) **
………………… 
 Skin   
 Spleen 
 Liver 
 Other  
 Additional 
………………… 
………………… 
      Single Mass 
      Whole 
      Mass 
 
     Tests     
………………… 
      Multiple 
       Mass 
      Lobe 
_____________ 
    (Fresh Tissue) 
………………… 
 GI 
          Masses 
      Panel for 
 
      Culture 
 Assess for 
………………… 
      Entire Digit 
      Endoscopic 
     Liver Disease 
           Aerobic 
………………… 
 
      Exploratory
     (includes extra 
    Completeness 
           Anaerobic 
 
      Derm Case
 Lymph Node 
………………… 
     stains: Copper, Iron 
    of excision**  
           Fungal 
 Oral 
………………… 
      Single 
    Trichrome, Reticulin 
      YES 
      Other Tests 
      Single  
 
 
      Multiple
     And Copper Levels*) 
      NO 
     ____________ 
      Multiple 
 
Location (for each tissue submitted): 
 
 
 
 
 
 
Distribution (single area, trunk and tailhead, generalized etc.): 
 
Ventral 
 
 
 
 
Description (crusts, pustules, invasive, pedunculated, etc.): 
 
 
 
 
Dorsal 
Duration (if known): 
Additional Relevant Clinical History/Treatment: 
 
 
Clinical Diagnosis/Differential: _____________________________________ 
Print Name:_________________________Signature:____________________________Date:_______________________ 
CF.ACC.12 Biopsy/Dermatopathology Submission Form                                                     1 of 1                                                                            September 2018                       JP 
Diagnostic Laboratory System 
 
AVDL 
www.labs.alabama.gov 
ACCESSION #: 
 
DATE 
Thompson Bishop Sparks State Diagnostic Lab 
RECEIVED: 
890 Simms Rd 
 
CASE 
Auburn, Al 36832 
 
COORDINATOR: 
Ph: (334) 844‐4987 
 
 
 CHARGE   N/C PAID:              CASH   CHECK #: 
Fx: (334) 844‐7206 
 
 
Auburn Lab  
 
 
Biopsy/Dermatopathology 
Tech Initials
 
 USPS    UPS    FEDEX     OTHER:  
 
Submission Form 
Submitted by:  Veterinarian  Owner  Other: 
 
** ALL submitted samples become the property of TBSSDL. Some testing may be subcontracted or referred out to qualified laboratories. You will be contacted for 
 
permission if this will incur further charges. TBSSDL no longer offers cytology. Please send samples directly to Auburn CVM Clinical Pathology Service. ** 
Veterinarian 
Owner 
Clinic 
County 
Address 
Address 
City                                State                    Zip 
City                                      State                    Zip 
Phone 
Phone                                  Fax 
Fax 
Email 
Email 
Previous Case # 
Report to:  Vet    Own    Other: 
Bill to:  Vet    Own    Other: 
Report Preference:  Email   Fax    Mail 
Bill Preference:  Email   Fax    Mail 
 
 
Specimen:  Fixed Tissue, Single    Fixed Tissue, Multiple    Fresh Tissue, Single    Fresh Tissue, Multiple 
Animal Name/ID 
Species 
Breed 
Sex 
Age 
 
(Lab Use 
 Please Mark All that Apply 
Only) 
* Liver copper levels require submission of fresh (unfixed) liver and incur an additional cost: $10.00) * 
………………… 
 
**Completeness of excision can only be assessed for excisional biopsies (masses submitted whole) **
………………… 
 Skin   
 Spleen 
 Liver 
 Other  
 Additional 
………………… 
………………… 
      Single Mass 
      Whole 
      Mass 
 
     Tests     
………………… 
      Multiple 
       Mass 
      Lobe 
_____________ 
    (Fresh Tissue) 
………………… 
 GI 
          Masses 
      Panel for 
 
      Culture 
 Assess for 
………………… 
      Entire Digit 
      Endoscopic 
     Liver Disease 
           Aerobic 
………………… 
 
      Exploratory
     (includes extra 
    Completeness 
           Anaerobic 
 
      Derm Case
 Lymph Node 
………………… 
     stains: Copper, Iron 
    of excision**  
           Fungal 
 Oral 
………………… 
      Single 
    Trichrome, Reticulin 
      YES 
      Other Tests 
      Single  
 
 
      Multiple
     And Copper Levels*) 
      NO 
     ____________ 
      Multiple 
 
Location (for each tissue submitted): 
 
 
 
 
 
 
Distribution (single area, trunk and tailhead, generalized etc.): 
 
Ventral 
 
 
 
 
Description (crusts, pustules, invasive, pedunculated, etc.): 
 
 
 
 
Dorsal 
Duration (if known): 
Additional Relevant Clinical History/Treatment: 
 
 
Clinical Diagnosis/Differential: _____________________________________ 
Print Name:_________________________Signature:____________________________Date:_______________________ 
CF.ACC.12 Biopsy/Dermatopathology Submission Form                                                     1 of 1                                                                            September 2018                       JP