<p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;"><span style="font-size: 10pt;">TACHAR EL TIPO DE ESTUDIO SOLICITADO:&nbsp; &nbsp;<o:p></o:p></span></b><b style="font-weight: bold;"><span lang="ES" style="font-size: 10pt; font-family: &quot;Times New Roman&quot;, serif;">BIOPSIA O HISTOPATOLOGÍA&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;CITOLOGÍA&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;NECROPSIA</span></b></p><p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;"><span style="font-size: 11pt; font-family: &quot;Times New Roman&quot;, serif;">HISTORIA CLÍNICA COMPLETA Y ANAMNESIS (Calendario de vacunas, desparasitaciones, dieta, tipo de lesiones, distribución, evolución, tratamiento, entre otros):</span></b></p><p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><br></p><p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;"><span style="font-size: 11pt; font-family: &quot;Times New Roman&quot;, serif;"><br></span></b></p><p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;"><span style="font-size: 11pt; font-family: &quot;Times New Roman&quot;, serif;"><br></span></b></p><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;"><span style="font-size: 9pt;">¿QUÉ TEJIDO ESTÁ ENVIANDO Y DE QUÉ REGIÓN SE REALIZÓ LA BIOPSIA O CITOLOGÍA (A.C.A.D./impronta/raspado/ hisopado)?<o:p></o:p></span></b></p><p class="MsoNormal" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"><b style="font-weight: bold;">&nbsp;</b><b style="font-weight: bold;"><span style="font-size: 12pt; font-family: &quot;Times New Roman&quot;, serif;">DIAGNÓSTICO PRESUNTIVO (DIAGNÓSTICO CLÍNICO):&nbsp;</span></b></p><p class="MsoBodyText" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif; text-align: center;"><b style="font-weight: bold;"><span style="font-size: 8pt;">TACHAR EN QUE ESTA CONSERVADA LA MUESTRA.<o:p></o:p></span></b></p><p class="MsoNormal" align="center" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px; font-family: Dosis, sans-serif;"></p><table class="MsoNormalTable" border="1" cellspacing="0" cellpadding="0" width="737" style="border-spacing: 0px; background-color: transparent; font-family: Dosis, sans-serif; width: 552.85pt; margin-left: -1.7pt; border: none;"><tbody><tr><td width="76" valign="top" style="padding: 0cm 5.4pt; width: 56.75pt; border: 1pt solid black;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">AIRE<o:p></o:p></span></p></td><td width="104" valign="top" style="padding: 0cm 5.4pt; width: 77.95pt; border-top: 1pt solid black; border-right: 1pt solid black; border-bottom: 1pt solid black; border-image: initial; border-left: none;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">ALCOHOL<o:p></o:p></span></p></td><td width="104" valign="top" style="padding: 0cm 5.4pt; width: 77.95pt; border-top: 1pt solid black; border-right: 1pt solid black; border-bottom: 1pt solid black; border-image: initial; border-left: none;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">FORMOL<o:p></o:p></span></p></td><td width="142" valign="top" style="padding: 0cm 5.4pt; width: 106.3pt; border-top: 1pt solid black; border-right: 1pt solid black; border-bottom: 1pt solid black; border-image: initial; border-left: none;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">EDTA/ HEPARINA<o:p></o:p></span></p></td><td width="142" valign="top" style="padding: 0cm 5.4pt; width: 106.35pt; border-top: 1pt solid black; border-right: 1pt solid black; border-bottom: 1pt solid black; border-image: initial; border-left: none;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">CONGELACIÓN<o:p></o:p></span></p></td><td width="170" valign="top" style="padding: 0cm 5.4pt; width: 127.55pt; border-top: 1pt solid black; border-right: 1pt solid black; border-bottom: 1pt solid black; border-image: initial; border-left: none;"><p class="MsoBodyText" style="margin-right: 0px; margin-bottom: 10px; margin-left: 0px;"><span style="font-size: 8pt;">OTROS (ESPECIFIQUE)<o:p></o:p></span></p></td></tr></tbody></table>