TISSUE REQUEST FORM

 San Diego Pathologists Medical Group, Inc.
7470 Mission Valley Road
San Diego, CA 92108
619.297-4900 Fax 619.297.5460
Courier 619.297.1140

Date Specimen Obtained:____________

Lab Accession No. _________________
Patient Name (Last, First) Name
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
 Sex
|___| 		Age
|___|___|
Patient Social Security Number
|___|___|___| - |___|___| - |___|___|___|___|
 Phone
|___|___|___| - |___|___|___| - |___|___|___|___|
Street Address
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
City
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|		 State
|___|___| 		Zip
|___|___|___|___|___|
Doctor Name and Number
- - -

PRE-OP/CLINICAL DIAGNOSIS:

TISSUE LOCATION:

  1. ________________________________________
  2. ________________________________________
  3. ________________________________________
FROZEN SECTION DIAGNOSIS:
BILLING INFORMATION: MUST BE PROVIDED OR CLIENT WILL BE BILLED
BIRTHDATE: |___|___|___|___|___|___|
ATTACH FRONT AND BACK COPY OF INSURANCE CARD
[_] Bill Patient
[_] Bill Medi-Cal #:
[_] Bill Medicare #:
[_] Bill CHAMPUS:
[_] Bill Other Insurance:

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