IPL : #5777

IPL : Idaho Pathology Laboratory

Surgical Pathology Requesition
Physician Information:
Name:*
UPIN#*
Phone/Fax:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information:
Name:*

First NameLast Name
Sex:*
DOB:*
SSN:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Billing Information:
Bill: (Please Choose One)*

InsuranceMedicareMedicaidPatient
Policy/Cert#*
Clincial Information:
Clinical Diagnosis:*
ICD-9:*
Status:*

New DiagnosisFollow upResidual Disease
Prior Pathology:*

BiopsySurgery
Specimen Information:

Type a question

	Specimen Location	Procedure	Post-Operative Diagnosis
A.
B.
C.
D.
E.

Authorized Signature*

Clear
Supply Request:

Requestion FormsFormalin Bottles
Should be Empty: