CanCan Diagnostics TEST ORDER FORM

Complete Form Below:

Order Ref:

Submitting Clinician:

Test Tube Number:

Vet Practice:

Vet Email:

Vet Tel:

Patient

Select Existing Add New

Pet Name

Owner Name

Pet DOB

Pet Species

Pet Breed

Pet Gender

Male Female

Neutered?

Yes No

Diagnosis

Location of Tumour

Stage of Tumour

Grade of Tumour

Suspected Metastasis

Date of Test

Date Posted

Previous Lab Ref (if applicable)

Sample Type(s):

Blood (Cell 3 Stabiliser) Tumour (FFPE) Tumour (FNA) Urine Urine is Stabilised Other? (Please specify)

If other (please specify)

Select Test(s):

All K9-LiquiDx URI - LiquiDx (sequencing) TMB - MSI BRAF Other? (Please Specify)

If other (please specify)

If submitting urine, please specify type:

K9 LiquiDx Info Required:

Aid Disease Diagnosis

Yes No

Aid Disease Monitoring

Yes No

Previous Sample(s) Submitted

Yes No

Additional Notes:

Please note that the services performed by CanCan Diagnostics are subject to the CanCan Diagnostics Terms & Conditions of Supply which were updated on 2023 and which are deemed to be incorporated into this contract. For a copy of these terms and information concerning the test methods employed, sample requirements and test pricing please contact CanCan Diagnostics.