Mammary Gland Tissue Donation Form

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 the 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