Biopsy Service Request
Patient
Patient ID
txtPatientID
Patient Name
txtPatientName
Client Name
txtClientName
Client Phone
txtClientPhone
Status
Alive
Died
Euthanized
Selection
Age
numAge
Breed
txtBreed
Species
txtSpecies
Sex
txtSex
Weight
numWeight
Referral
Contact Name
txtReferralContactName
Contact Email
txtReferralContactEmail
Contact Phone
txtReferralContactPhone
Clinic Name
txtReferralClinicName
Clinic Email
txtReferralClinicEmail
Clinic Phone
txtReferralClinicPhone
Address 1
txtReferralAddress1
Address 2
txtReferralAddress2
City
txtReferralCity
State
txtReferralState
Postal Code
txtReferralPostalCode
Biopsy
Biopsy Tissues Submitted
txtBiopsyTissuesSubmitted
Date Taken
Time Taken
tmTimeTaken
Biopsy Type
Biopsy (in formalin jar)
Biopsy (fresh - limb, tail, etc.)
Necropsy (in formalin jar)
Referral Slide
Whole Brain
Selection
Jars
None
1
2
3
4
5
6
7
8
9
10
Selection
txtJarCount
Previous Biopsy
VMTH
Outside institution
Unknown
Selection
Institution
txtPreviousBiopsyOutsideInstitution
Previous Biopsy Attachment (optional - 30MB max)
Attach
Detach
Mandatory Special Review
None
Dermpath
Neuropath
Ophthalpath
Orthopath
Renal
Other
Selection
Other Mandatory Special Review
txtMandatorySpecialReviewOther
Mandatory Special Review Attachment (30MB max)
Attach
Detach
Person to be contacted at time of trimming
txtToBeContactedName
...
Email
txtToBeContactedEmail
Phone
txtToBeContactedPhone
Special Requests (select all that apply)
RUSH or STAT (verbal diagnosis next day)
Trimming (large specimens, mammary chains, legs, spleens, tumors)
Margin Check (each six sections)
Clonality T cell
Clonality B cell
Renal Biopsy Protocol
Diagnostic Special Stains (included in initial biopsy cost, if no IHC)
txtDiagnosticSpecialStrains
Diagnostic Immunohistochemistry (per slide-first free if no special stain)
txtDiagnosticImmunohistochemistry
Other
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