To be completed at Charles River

LTM Order Number:

Date Received:

Histopathology Submission Form

Sponsor Information * = required Bill To Information Same as Sponsor Payment information required
at the time of submission.
Institution* Institution*
Pay by PO
Address 1* Address 1*
PO #
Address 2 Address 2
Pay by Credit Card (CC)
City* City* Contact

State* Zip Code* State* Zip Code* Phone

To make payment with CC on file,
Contact* Contact* indicate last four (4) digits and
expiration date. For CC security,
Phone* Phone* do not write full CC number.
CC Last 4 Digits
Email* Email*
CC Exp Date

Sample Information
To the best of my knowledge these samples and/or specimens do not contain any infectious agent or material which might pose a threat to
human health. If this is not the case, please call Charles River before sending samples.

Signed: Date:

Sample Type: Fixed Tissues Fixed whole animal H&E stained slides Paraffin blocks

Please use one form per species.

Species: Total Number of Samples: Ship Date: Source/Room:

Sample Protocol Code Sample or

Group ID Age/DOB of Animal Sex Strain
# (See Page 2) Animal ID
1
2

Clinical History
(attach an extra
page if needed):

Page 1 of 2
 Protocol Code Protocol Description

HPI H&E slide preparation with interpretation

INT H&E slide interpretation only
NEC Gross exam on fixed whole animal with HPI
PEO Process to paraffin embed only
BHO Block to H&E stained slide only
USO Block to unstained slide only
SPS Specific histochemical stain, specify in Clinical History section on page 1
DIG Digital photomicrographs

Shipping Instructions

Shipping procedure varies with sample submitted and should be discussed with Charles River Customer support
prior to shipping. North America: 1.877.274.8371, International: +800.3195.3430 or askcharlesriver@crl.com.

Sample Submission:
Place a copy of page 1 in the appropriate shipping container with your samples. Please follow International Air
Transport Association (IATA) guidelines.

Charles River provides IATA-compliant insulated shipping containers free of charge. Simply contact Charles River
Customer Support (North America: 1.877.274.8371, International: +800.3195.3430) to request boxes for
diagnostic testing. Alternatively, you may order shipping containers via our website at www.criver.com/info/quotes.

Submit your samples to Charles River: Print Form

Charles River Charles River Charles River

RADS RADS RADS
Histopathology Lab West Coast Laboratory Building H5 SAS Échantillons
261 Ballardvale Street 10788 Roselle Street Domaine des Oncins
Building 22 Loading Dock San Diego, CA 92121 BP 0109
Wilmington, MA 01887 USA 69592 L'Abresle Cedex
USA France

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