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Mammary Gland Tissue Donation Form

If you think you may have tissues that would help our project, please answer as many of the questions below as you can.

Asterisks (*) denotes required field.

Title
Owner's First Name*
Owner's Last Name*
E-mail Address*
Phone Number*
Cat's Name*
Breed
Age*
Gender (Note: we need samples from female cats only)*

Is the mammary tissue tumoral (from a tumor) or normal?
If the tissue is tumoral, what is the histopathologic diagnosis (if known)?
If the tissue is normal, was it obtained through surgery?
If so, what type of surgery?
If the cat was put down, what was reason?

Number of past pregnancies
Spayed?
If yes, list the age of spaying

History of pathologies of reproductive system:
If yes: which pathologies?
Other relevant diseases

Veterinarian’s Name
Veterinarian’s E-mail Address
Veterinarian’s Phone Number