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ORAL PATHOLOGY SUBMISSION FORM

Specialty Oral Pathology for Animals,LLC
Dr. Cindy Bell
637 N. State St.
Geneseo IL 61254
309-944-6373
dr.bell@sopforanimals.com
SUBMITTING VETERINARIAN INFORMATION
Veterinarian:

Clinic name:

Address:

City:

State:

ZIP:

Email*:

Separate multiple email addresses with a semicolon.
Phone:

* Reports are emailed unless requested otherwise.
SPECIMEN INFORMATION
Location, size and description of lesion (i.e. color, pedunculated, ulcerative, lytic, etc.)
Biopsy Type

Are margins included?

Duration of problem:

Previous biopsy?
Yes: No:
If SOPA, please give case #

If other lab, please include report.
HISTORY
Include all relevant dental/medical history, current problem, clinical/surgical findings, & diagnostic imaging findings:
Information provided here will be transcribed to the pathology report.
Clinical/differential diagnosis:
Other information or requests:
This information will NOT be transcribed to the pathology report.
LAB USE ONLY
Accession #
Date received:
Bill code:
PATIENT INFORMATION
Owner Name:

Pet Name:

Species:
Breed:

Age:

Sex:

Clinical photographs and/or diagnostic imaging greatly enhance the precision and accuracy of diagnosis. Images may be submitted in print, emailed to us directly, or uploaded electronically from this form.
Upload relevant files:
(Allowed file types: DOCX, XLSX, PDF, JPG, PNG)
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