SURGICAL PATHOLOGY AND NON-GYN CYTOLOGY REQUISITION FORM
Tissue specimens and non-gyn cytology specimens must be submitted with this form. All specimens must be properly identified.
- Print information on container label
- Patient’s first and last name
- Source of specimen
- Physician name
- Date of specimen collection
- Requisition form must be properly and fully filled out on each patient
- Patient name (last, first, middle initial)
- Patient social security number
- Patient age
- Patient sex
- Patient date of birth (month, day, year)
- Physician name
- Patient address
- Patient insurance information
- Date specimen collected
- Requested procedure
- Pre-op diagnosis (IDC-9 code preferred)
- Post-op diagnosis (ICD-9 code preferred)
- Type and location of specimen
- Special requests (NOTE: Punch biopsy margins are not routinely checked. If punch biopsy margins are to be checked, please make request in this space.)
- Multiple specimens from single patient
- Only one requisition form is required
- Each container must be numbered
- Each corresponding number must be written on requisition with source of each specimen.
- 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.
- 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.