/ HISTOPATHOLOGY REQUISITION FORM

Please provide the following information and submit with specimens. A valid Purchase Order (PO) number oraccounting reference number must be provided.Submit with specimens, or fax this form to (408) 738-9278 or email to or

Sponsor or Contact : / Study No.:
Company Name: / Phone:
Address: / Fax:
Email:
Completion Date: / PO:
GLP Study: / Yes: No: if YES, Provide GLP protocol
Species: / MouseRatDogCatRabbitGuinea PigRabbitHamsterPigHumanXenograftCell PreparationNon-human Primate / Specimen ID #
Check type and number of specimens submitted (Check all individual tissues to be processed on page 2)
Whole animal / # / Unstained slides / #
Untrimmed tissues / # / Paraffin blocks / #
Trimmed tissues / # / Frozen blocks / #
Cassetted tissues / # / Frozen block prep from tissues / #
Indicate Fixative: / NBFMod Davidson'sGlutaradahydeBouin's SolutionDavidson'sAlcoholUnfixed
Other: / Undecalcified bone / #
Check services requested:
Prepare H&E stained slides / Immunohistochemistry
Unstained sections / Antibody:
Special Stains / Antibody:
Special Stains / Antibody:
Plastic sections GMA MMA / Antibody:
Gelatin / Antibody:
Prepare paraffin blocks only
Hold tissues without prep
Prepare for archiving or shippingonly / Other:
CBI Pathologist Evaluation: / Yes No
Detail any hazards:
Detail any special requirements:
Comparative Biosciences, Inc. Histology Laboratory Use Only
Accession Date: / Specimen return:
By sponsor
By CBI
Courier
Shipping / Slide boxes #
# Containers: / Block boxes #
Condition of Specimens: / Undamaged Damaged:
Explain: / Dry Ice
Bagged #
Client Code: / Accession No: / Sent to Archive Date:

IfCBI Study: Study Number:CB---______CBI Study Director ____

(To be filled out by CBI Personnel)

Check all tissues to be processed (for GLP studies, attach protocol and tissue list):

Organ / Organ
Adrenal glands (paired) / Liver (2 lobes)
Aorta (thoracic) / Lungs with bronchi (2 lobes)
Bladder, urinary / Lymph nodes ( inguinal, mesenteric, mandibular)
Bone / Macroscopic lesions
Femur / Mammary gland (inguinal)
Sternum / Pancreas
Bone Marrow / Pituitary gland
Femur / Reproductive - Female
Sternum / Cervix/Uterus
Bone Marrow Smear / Ovaries (paired)
Brain (cerebrum, cerebellum, mid-brain) / Oviducts (paired)
Esophagus / Vagina
Eyes with optic nerve / Reproductive - Male
Gall bladder / Epididymis
Harderian Gland / Prostate
Heart / Seminal Vesicles
Injection site / Testes (paired)
Kidneys (paired) / Salivary gland
Lacrimal Gland / Sciatic nerve
Small Intestine / Skeletal muscle
Duodenum / Skin & subcutis (inguinal)
Jejunum / Spinal Cord (cervical,lumbar, thoracic, with vertebrae)
Ileum / Spleen
Large Intestine / Stomach
Cecum / Thymus
Colon / Thyroid/parathyroid
Rectum / Tongue
Other: / Trachea
Other: / Other:
Other: / Other:
Wet Tissues: / Return to sponsor / Ship to*:
Slides: / Return to sponsor / Ship to*:
Blocks: / Return to sponsor / Ship to*:
* If different address
Method of Shipment and Shipping Number:
Note: All wet tissue will bediscarded unless otherwise specified above. Sponsor accepts financial responsibility for all expenses associates with wet tissue handling, storage, discarding and shipping. Unless otherwise requested, Comparative Biosciences, Inc. may discard any nonGLP specimens that are unclaimed after 3 months without further notification to the sponsor.
Client Signature: / Date:

Note: Upon signature or upon submission of specimens, sponsor agrees to accept all financial responsibility for all expenses associated with the work requested in this Histology Requisition Form. The sponsor accepts the terms and conditions of the CBI histology project agreement. Sponsor agrees to payment terms as set forth in the study invoice which is 100% due within 30 days following presentation of the invoice.

______

Comparative Biosciences, Inc. 786 Lucerne Drive, Sunnyvale, CA 94085 HLF001.24

408 738.9260 fax 408 738 9278 07Oct15

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