DELIVER TO: Clinical Flow Cytometry Laboratory

S-763 Scaife Hall, 3550 Terrace Street

Pittsburgh, PA 15261

Tel: (412) 624-3746 Fax: (412) 624-6863

Call to notify lab prior to sending specimens.

Space for optional addressograph

PATIENT INFORMATION– Complete all fields. Attach patient insurance/demographic information. PLEASE PRINT.

Last Name First Name M.I.

Social Security Number

□ Outpatient

□ Inpatient – Room #

Birth Date

Sex

Diagnosis

ICD 9 Code

Requesting Hospital Medical Record Number and/or Surgical Number:

REPORTING INFORMATION – Complete all fields. Attach surgical pathology report with gross description.

Requesting Physician Name

Phone (Including Area code)

Fax (Including Area Code)

Institution Name

Phone (Including Area code)

Fax (Including Area Code)

Copy to: Physician name

Phone (Including Area code)

Fax (Including Area Code)

Name of person filling out form: Phone #:

CLINICAL HISTORY/PERTINENT PHYSICAL FINDINGS:

______________________________________________________

(use back of requisition as needed)

Pre-op Diagnosis: _______________________________________

Post-op Diagnosis: _____________________________________

Procedure: ____________________________________________

TYPE OF SPECIMEN

Specify site and type of specimen: ______________________________________________________________________________

Time & Date specimen obtained:

Time & Date specimen sent:

LYMPH NODE/SOLID TISSUE TESTING REQUEST

□ Entire specimen for full hematopathologic evaluation

□ Portion of specimen – specify testing below (remainder to follow for: □ consultation or □ primary report)

FLOW CYTOMETRY TESTING REQUEST

□ Flow Cytometric Immunophenotypic Studies (Indicate any special requests) __________________________________

MOLECULAR ONCOLOGY

□ DNA/RNA Extraction and Storage

□ Molecular Studies (specify): ________________________________________________________________________

CHROMOSOME ANALYSIS

□ Classical Cytogenetic Analysis (for Hematologic Malignancy Workup)

□ FISH Study: Indication ____________________________________________________________________________

Signature of Requesting Physician * REQUIRED *: ___________________________________________________________________________

Steven H. Swerdlow, MD

Director, Division of Hematopathology

(412) 647-5191

Fiona Craig, MD

Director, Flow Cytometry Laboratory

(412) 647-8504

Judith Bright, MS, MT(ASCP)SH

Supervisor, Special Hematology

(412) 624-2167