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Animal Urinary Stone Analysis

by infrared (IR-) Spectroscopy

ADDRESS TO BE FILLED BY THE SENDER (Please use capital letters or stamp)

Request Form

Prof. Dr. rer. nat. Albrecht Hesse - Harnsteinanalysezentrum Bonn -

Theaterplatz 14 D - 53177 Bonn

Date of reception:

Fon: +49 228 95737 16 Fax: +49 228 95737 21

Reg.No. of the IR-Lab:

Result to the sender by (F)ax/(P)ost on:

Please, do not send urine or blood!

(20 per Analysis - 2009)

Stone removal: Pretreatment: diet spontaneous medicament for chemolithic urohydropropulsion which? ............................. endoscopy ......................................... surgery lithotryptic catheter Localization of the stone: kidney right kidney left ureter right ureter left bladder bladder and ureter

To be filled in by the sender:

Name or registration number of the animal: ................................................................................. Other species: Dog Cat ........................ Male Female Castrated

Breed ............................................. Animal's age (years) Weight (kg) Obese (0 = no, 1 = yes)

Remarks: ............................................................................................ Results to be returned by fax (0 = no, 1 = yes): Fax-No.: .............................................................................................. Date/Signature: ..................................................................................

To be filled in by the laboratory:

Stone weight (g) .......................... Number of stones ........................ Gravel Colour Surface

(0 = no, 1 = yes) 1 - white 2 - yellow 1 - rough

Result: values in % of weight

Total

Whewellite Weddellite Carbonate-Apatite (Dahllite) Brushite Struvite

7 - grey

.................

3 - black 5 - green 4 - brown 6 - beige 2 - smooth 3 - bizarre

Uricite Ammoniumurate Cystine Xanthine Calcite

Date/Signature ......................................................

www.harnsteinanalysezentrum-bonn.de

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