Send directly to:
Canadian Veterinary Urolith Centre
University of Guelph, Laboratory Services Division,
95 Stone Rd. W.,
Guelph, ON. N1H 8J7 (If sending by courier use: N1G 2Z4)
Phone: 519-823-1268 ext. 57454 Fax: 519-767-6240 Email: email@example.com
NOTE: SUBMITTING CLINICS ARE RESPONSIBLE FOR SHIPPING CHARGES.
PLEASE SUBMIT CLEAN DRY UROLITHS, CRYSTALS AND URETHRAL PLUGS IN A CLEAN PLASTIC VIAL.
Clinic Name: Pet Name:
Address: City: Owner’s Last Name:
Province: Postal Code:
Species: Canine Feline Other*:
e Female Neutered/Spayed: Yes No
If Yes: Before stone removal
At or post stone removal
Email: Age: ________________Year(s) ________________Month(s)
Specimen submitted: Urolith(s) Urethral plug Sediment Crystals
Source of urolith(s): (check all applicable): Renal Pelvis Ureter(s) Bladder Urethra Other ________________
Method of removal: Voided naturally Cystotomy Voiding Urohydropropulsion Lithotripsy +/- basket removal
Percutaneous cystolithotomy Laparoscopic assisted cystotomy Other ___________________________________________
Does the patient have renal disease?
Yes No Unknown
Is the patient hypercalcemic?
Yes No Unknown
List other concurrent diseases (if applicable) List medications (if applicable)
Body condition: Thin Ideal Overweight Weight: __________ kg lb
Environment of animal: Mostly Outdoor Mostly Indoor Indoor + Outdoor
# of OTHER animals on premises: Cats: ____ Dogs: ____
Primary diet (at time of diagnosis): Homemade / Table Food / Raw Grocery / Pet Store Veterinary Unknown
Primary diet type (at time of diagnosis): Wet Dry Mixed Semi-Moist Unknown
Does this patient have a previous history of Urolith(s)?
Yes No Unknown
CANADIAN VETERINARY UROLITH CENTRE
IF YES PLEASE PROVIDE INFORMATION BELOW REGARDING THE PATIENT’S PREVIOUS UROLITH(S):
Previous urolith method of removal: Voided naturally Cystotomy Voiding Urohydropropulsion
Lithotripsy +/- basket removal Percutaneous cystolithotomy Laparoscopic assisted cystotomy Other _______________
Composition: Struvite Calcium Oxalate Calcium Phosphate Urate Other ___________________________
Source (check all applicable): Renal Pelvis Ureter(s) Bladder Urethra Other ___________________________
Previous urolith removal date(s): ____________________________________________
Previous urolith report number(s) (if available): ____________________________________________
Preferred language of correspondence: English French
Preferred report delivery method: Email Fax
Results also available on the Royal Canin Veterinary Portal at vet.royalcanin.ca.
NOTE: ALL FIELDS MUST BE COMPLETED IN FULL TO PROCEED WITH ANALYSIS.
ANY MISSING INFORMATION WILL RESULT IN DELAYS.
This $50.00 urolith analysis* provided
compliments of Royal Canin.
Information collected by University of Guelph Laboratory Services will be subject to the Freedom of Information and Protection of Privacy Act (Ontario) and
the University of Guelph Privacy Statement [www.uoguelph.ca]. Submitting Veterinarian is responsible for obtaining any or all necessary consents from pet
owners and to explain that data collected or created through these testing services may be used by the University of Guelph and Royal Canin for research,
product development and case studies posted to the Royal Canin Veterinary Portal at vet.royalcanin.ca. This information may be used for research, we
appreciate efforts to provide as accurate information as possible. Please keep a copy of this form for your records.
* The Canadian Veterinary Urolith Centre is pleased to analyze uroliths from all species except humans and non-human primates.
Canine and Feline urolith analysis provided compliments of Royal Canin. Clinics are responsible for the shipping charges as well as
the cost of the analysis of non-canine and non-feline uroliths.