ORAL
PATHOLOGY GROUP
INDIANA
UNIVERSITY SCHOOL OF DENTISTRY
1050
Wishard Boulevard, Room R4201
Indianapolis,
Indiana 46202-2859
Telephone:
317 274 7668
Facsimile:
317 274 3346
Email:
ds-opath@iupui.edu
|
LAB
USE ONLY
Received
Date:
Path #:
|
Biopsy
Information
|
Date
of Biopsy:
Biopsy
Site:
Surgical
Procedure:
Clinical
Description:
Radiographic
Description:
Provisional
Diagnosis:
|
Patient
Information
|
Patient
Name:
Address:
Phone:
Home:
/
Work:
/
SSN:
- -
Date
of Birth:
/ /
Sex:
Race:
Bill:
( )
Patient
( ) Insurance
Name
of Insured:
Relationship: ( ) Spouse ( )
Self ( ) Other
Insurance
Company: ID/Policy Number:
Address:
I
understand that the diagnostic laboratory services may not be covered by
Medicare or other insurance and I will be responsible for the charges
incurred.
Patient Signature:
(I hereby assign benefits to the Oral Pathology Group)
|
Doctor
Information
|
Submitting
Doctor:
Signature:
(Required by CLIA88)
Address:
Phone:
/
FAX:
/
E-mail: _______________
Please
send more biopsy kits:
6
Pack
12 Pack
|
|
|
Click
here for information on biopsy kits.
Click
here to view a sample report.
Click
here to return to the Oral Pathology Group main page.
Back to
OPMR main page.