Molecular Fungal ID Lab Submission Form Please print your confirmation email and submit it with the shipped specimen. Submission Date(Required) MM slash DD slash YYYY External ID Patient Name(Required) Submitter Name(Required) First Last Clinician Name(Required) First Last Owner Name(Required) First Last Species(Required) Breed(Required) Gender(Required)MaleM-NeutFemaleF-SpayUnkn/OtherAge(Required) Pathologist Name(Required) First Last Clinic Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Clinic Email Address (For Lab Results)(Required) Clinic Email Address (For Invoicing, if different) Clinic Phone Number(Required)Clinic Fax NumberTissue Type Submitted(Required) Sample Type Submitted(Required) Paraffin Block Paraffin Scrolls Formalin Fixed (Additional Fees Apply) Fresh/Frozen (Additional Fees Apply) Slide Submitted(Required) H&E GMS PAS Cytology Unstained Slide (Additional Fees Apply) History(Required)Histologic Findings and Diagnosis(Required) Upload Medical Records or Reports (Optional)Max. file size: 125 MB.EmailThis field is for validation purposes and should be left unchanged.
