Blood Typing and Compatibility Submission Form


Send Samples to: Email: penngen@vet.upenn.edu Phone: (215) 898-3375/8894 Fax: (215) 573-2162	Dr. Giger/(state test requested) PennGen Testing Lab 3900 Spruce Street, Room 4013 Philadelphia, PA 19104-6010	Visit our Website @: www.vet.upenn.edu/penngen All information will be kept confidential.

Blood Typing and Compatibility Submission Form

For blood typing, sample must arrive within 3 days of collection.
Coombs and Crossmatch samples must be shipped on ice in an insulated container by overnight mail.

Sample Submitted:
EDTA Whole Blood (required) Serum/Plasma Other:
Collection Date: Shipping Date:

Send Report To:
Veterinarian Owner/Agent Both Veterinarian and Owner/Agent

Veterinarian Information: (if clinic submits samples)
Name:	Hospital Name:
Address (line 1):	Phone:
Address (line 2):	Fax:
City:	Email:
State:	Zip Code:
Country:

Owner/Agent Information: (if different from above)
Name:	Hospital Name:
Address (line 1):	Phone:
Address (line 2):	Fax:
City:	Email:
State:	Zip Code:
Country:

Patient Information: (call name, species and breed required)
Patient's Official Name:	Call Name:	Age:
Species:	Breed:	Sex: M F	Neutered?: Yes No
AKC (yes/no or specify):	Registration Number:	Other Comments:

Test Requested: (check all that apply)	Reason for Testing: (check all that apply)
Blood Typing ($25): Dog: DEA 1.1 Dal Other - specify: Cat: AB group Mik Other - specify: Crossmatch ($75) Coombs ($50)	General Blood Typing Breeding Potential Blood Donor Suspicious Clinical Signs Compatibility for Transfusion Other (please put reason in comments section)

Comments:

Please label all samples with animal's call name and owner's last name and date. Include credit card information below (credit card information needed: VISA/MasterCard, expiration date, name as it appears on the card, card number) or a check payable to "University of Pennsylvania Trustees/Dr. Giger."