FINE NEEDLE ASPIRATION PROCEDURE REQUISITION CONTRA COSTA PATHOLOGY ASSOCIATES 399 Taylor Blvd, Suite 200 Pleasant Hill, CA 94523 Phone (925) 270-3575 Fax (925) 270-3589 www.cocopath.net Nicholas Byrne, M.D. Christine Cesca, M.D. Jeffrey Curtis, M.D. Dennis Hwang, M.D. Barry Latner, M.D. Rajni Mandal, M.D. Risha Ramdall, M.D. Nader Shihabi, M.D. REQUIRED PATIENT INFORMATION Last Name First Name Date of Birth [ ] Male COLLECTION DATE [ ] Female ORDERING PHYSICIAN NAME (Last, First) PLEASE PRINT Address PHYSICIAN OFFICE INFORMATION City State Home Number Work Number ( ( ) BILLING DIAGNOSIS Zip ) ATTACH BOTH SIDES OF ALL INSURANCE CARDS ICD9: COPIES TO: COPIES TO: CLINICAL INDICATIONS CLINICAL HISTORY To be completed by referring physician. If you have special instructions, please call us. Ultrasound guided technique may be used if necessary to Enhance localization. Location for procedure: Right Left (if applicable) DESCRIPTION OF PROCEDURE You have been referred for a Fine Needle Aspiration (FNA) biopsy because a lump was discovered and your doctor wants to determine its nature. FNA is a diagnostic procedure in which a thin, hollow needle is inserted into the mass to extract cells. The cells will be stained and examined under a microscope and the results will be delivered to your doctor in 24-48 hours. The site of the extraction will leave a mark no bigger than a needle stick from a blood test. It may feel sore or bruise for a few days after the procedure but significant complications are rare. You may resume your normal activities after the procedure. Go to www.cocopath.net for more details. PATIENT INSTRUCTIONS Please bring this form with you to your appointment. Please call to schedule an appointment. Plan to arrive 15 minutes prior to your appointment to register. The entire procedure can be completed within 30 minutes. If you cannot keep your appointment, please call to let us know and to reschedule. Remember you MUST bring your current insurance card, a form of identification and this form with you at the time of your appointment. It may be convenient to wear a two-piece outfit (no turtleneck shirts).. Do not take aspirin or blood thinners a minimum of 48 hours prior to the biopsy. You may eat and drink as usual. DIRECTIONS FNA Clinic/CoCoPath 399 Taylor Blvd, #200 Pleasant Hill, CA. (925) 270-3575 [email protected]