LABORATORY REQUEST
CYTOLOGY
Patient Demographic Information
Name
MRN
This form when completed constitutes a referral to VIHA laboratory physicians.
Encounter
ORDERING PHYSICIAN
Last name, First name
Birthdate (dd/mmm/yyyy) GENDER
MSP PRACTITIONER #
PHN
Copy of results to:
Last name, First name MSP#
Location / Address
Last name, First name MSP#
Last name, First name MSP#
PHYSICIAN SIGNATURE:
Date Collected: dd/mmm/yyyy
Time Collected:
Collected By: (print)
Exact Site and Type of Sample: ** Fix Cytology Samples in CytoLyt
®
Sample
Laterality/Location
Initials/Signature
1
Sputum
Washing
Brush
Lavage
FNA
Fluid
Urine voided
Urine catheterized
Other - Specify
2
Sputum
Washing
Brush
Lavage
FNA
Fluid
Urine voided
Urine catheterized
Other - Specify
3
Sputum
Washing
Brush
Lavage
FNA
Fluid
Urine voided
Urine catheterized
Other - Specify
4
Sputum
Washing
Brush
Lavage
FNA
Fluid
Urine voided
Urine catheterized
Other - Specify
Total number of samples submitted for Cytology:
If more than 4 samples, please use an additional requisition and submit all samples and requisitions together.
(10-05-0260-0) REPLACEMENT FORM: 20150526/DN Page ___ of ____
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