HISTOLOGY SPECIAL REQUEST FORM

TO:

San Diego Pathologists Medical Group, Inc.
Histology Department

Phone: 619.297.4900
Fax: 619.297.5460
FROM:

 

 

 
HISTOLOGY REQUISITION
PATHOLOGIST: DATE: DELIVER TO:
SURGICAL #: OUTSIDE BLOCK:
BLOCK #: RUSH: ROUTINE: B-5 FIXED:
RECUTS x STEPS x START AT LEVEL #
SPECIAL INSTRUCTIONS
POST FIX IN B-5
STEP THRU BLOCK PULL SLIDE(S)
RE-EMBED AND CUT PULL BLOCK(S)
THINNER SECTIONS PULL TISSUE
SLIDES ALREADY CUT REPAIR SLIDES
SPECIAL STAIN

HISTOCHEMISTRY:

 

 

 

IMMUNOHISTOCHEMISTRY:

 

 

 

COMMENTS:

 

 

 

COMMENTS:

 

 

 

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