PATIENT NAME:_____________________________________________________
PATIENT ADDRESS: ___________________________________________________________________
______________________________________________________________________________________
SOCIAL SECURITY #: ____-____-____ TEL. No.: ________________
DATE OF BIRTH _____/_____/_____ AGE_____ SEX_____RACE______MARITAL STATUS: S M D W
CLINICAL HISTORY (REQUIRED FOR ALL SPECIMENS)______________________
____________________________________________________________________________
____________________________________________________________________________
DATE OF PROCEDURE____/____/____
BILL TO: (circle one) Pathology Lab Hospital Patient (supply billing information)
PLEASE LIST CONTAINERS WITH TISSUE SITE IN THE PLACE PROVIDED BELOW:
SITE FIXATIVE
A. _________________________________________________________________________
B. _________________________________________________________________________
C. _________________________________________________________________________
CLINIC/HOSPITAL NAME: ____________________________________________________
ADDRESS: _________________________________________________________________
CITY:__________________________________STATE: ________________ZIP: __________
FAX #:_____________________________
PHONE #: _________________________
ORDERING PATHOLOGIST (PRINT NAME AND SIGN – REQUIRED FOR ALL SPECIMENS)
________________________________________________________Phone #____________
QUESTIONS – SURGICAL PATHOLOGY SPECIMEN ACCESSIONING (919) 681-3909
AFTER HOURS – SURGICAL PATHOLOGY TECHNICIAN BEEPER (919) 970-6931