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Quantitative Urolith Analysis Submission Form
Visit our website at: www.cvm.umn.edu/depts/MinnesotaUrolithCenter
Urinalysis and urinary case history:
CLINIC INFORMATION
Date: ___________________________________________________ Date _________________Composition _________________________ Veterinary Surgeon: ______________________________________ Date _________________Composition _________________________ Clinic Name: _____________________________________________ Was the urine cultured within one month of urolith detection? Address: ________________________________________________ ________________________________________________________ Isolates ____________________________________________________ __________________________ Postcode: ____________________ Medication:
Telephone: ____________________ Fax: _____________________ Were antibiotics given within one month of urolith detection? Email: __________________________________________________ Type and dosage ____________________________________________ CLIENT AND PATIENT INFORMATION
___________________________________________________________ Owner’s Name:___________________________________________ Animal’s Name: __________________________________________ Species: _________________________________________________ Dosage and duration ________________________________________ Breed (specific): __________________________________________ ___________________________________________________________ Birth Date: ______________________________________________ Other previous illness or injury:
Does the patient have any of the following illnesses or injuries?
Source of urolith: (tick all areas samples obtained from)
If “Other”, please specify _____________________________________ Other ______________________________________________________ Sample retrieval method:
Surgical
Other ______________________________________________________ Date retrieved _____________________________________________ Date clinical signs first noted __________________________________ • CANINE and FELINE urolith samples only. • Send stones DRY (formalin or other liquid). Dietary history:
• DO NOT send urine samples or sediment.
What type of diet was primarily fed prior to urolith detection? • Label sample with the ANIMAL’S NAME and • Analysis is provided to your clinic at no charge. Commercial/Prescription Food If a commercial/prescription diet was fed, list the primary diet fed Post to: Urolith Analysis Service, Hill’s Pet Nutrition Ltd, Building 5, Croxley Green Business Park, Watford, Hertfordshire ___________________________________________________________ WD18 8YL, UK To avoid delay in the post please ensure correct postage is paid. Telephone 0800 282438 / 1800 626002 (ROI) Tick here if you wish to receive more submission forms. Alternatively, please visit www.hillspet.co.uk/urolith or www.hillspet.ie/urolith
™Trademarks owned by Hill’s Pet Nutrition, Inc. 2011 Supported in part by an educational gift from Hill’s Pet Nutrition. Version 2011

Source: http://www.hillspet.ie/urolith.pdf

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