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
Name of MCO HEALTHCHOICE MCO DRUG USE MANAGEMENT PROGRAM ANNUAL ASSESSMENT February 2007 The Maryland Medicaid Pharmacy Program, Division of Clinical Pharmacy Services is responsible for monitoring and approving each MCO’s drug use management program. Approval of your MCO’s drug use management program for FY 2008 will be determined by a review of your formulary and your responses