Fillable External- Consult- Request 1 18 (CellNetix Pathology & Laboratories)

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External- Consult- Request 1 18 (CellNetix Pathology & Laboratories)

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CellNetix Consult Request Form
CellNetix Pathology & Laboratories 866-236-8296 www.cellnetix.com
Patient name
DOB
Name of laboratory where
slides are located
Phone of above lab
Date of original service
Accession/case number
ICD-10 code
Requesting facility
Requesting physician
(printed name)
____________________________________ ____________
Requesting Physician Signature Date
Please FAX to: 206-576-6711
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External- Consult- Request 1 18 (CellNetix Pathology & Laboratories)

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Completed 12 August 2021

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