Tissue specimens and non-gyn cytology specimens must be submitted with this form. All specimens must be properly identified.

  1. Print information on container label
    1. Patient’s first and last name
    2. Source of specimen
    3. Physician name
    4. Date of specimen collection
  2. Requisition form must be properly and fully filled out on each patient
    1. Patient name (last, first, middle initial)
    2. Patient social security number
    3. Patient age
    4. Patient sex
    5. Patient date of birth (month, day, year)
    6. Physician name
    7. Patient address
    8. Patient insurance information
    9. Date specimen collected
    10. Requested procedure
    11. Pre-op diagnosis (IDC-9 code preferred)
    12. Post-op diagnosis (ICD-9 code preferred)
    13. Type and location of specimen
    14. Special requests (NOTE: Punch biopsy margins are not routinely checked. If punch biopsy margins are to be checked, please make request in this space.)
  3. Multiple specimens from single patient
    1. Only one requisition form is required
    2. Each container must be numbered
    3. Each corresponding number must be written on requisition with source of each specimen.
  4. Adhesive labels on each requisition that can be placed on the tissue specimen container for added identification. These are especially helpful for specimens with multiple parts. There is a space on each label to indicate the specimen source or site. The number on the label (#1, #2, etc.) should match the corresponding specimen number on the requisition.
  5. Clinic/hospital keeps pink copy of requisition, and sends top two (white and yellow) copies, in bio-hazard bag with specimen, to WPM. The folded requisition should be placed in the pocket on the back of the bio-hazard bag, separated from the specimen container to avoid contamination from unexpected leaking of the specimen container.

contact us

  • WPM Pathology Laboratory
  • 338 N. Front St.
  • Salina, KS 67401
  • 785.823.7201