LABORATORY REQUEST
HISTOLOGY
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
Collected By: (print)
Sample
OR Use Only
Time Collected
Signature
1
Stat IOC
2
Stat IOC
3
Stat IOC
4
Stat IOC
5
Stat IOC
6
Stat IOC
Total number of samples submitted for Histology:
(18-05-0072-0) REPLACEMENT FORM: 20150526/DN Page ___ of ___
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome