Histology Processing Request Form LAB USE ONLY CLIENT INFORMATION Advanced Clinical Laboratories “Focusing on Anatomic Pathology” HP 01001 1138 Wilshire Blvd., Suite 305, LA, CA 91007 Tel: (213) 250-8017 • Fax: (213) 250-8019 Processing Date: Ordering Pathologist/Physician: Hospital: Fixative for Processing (select one) B5 Bouin’s item Block ID Number Ethanol Facility: Total Blocks Formalin Number of Number of Pieces Cassettes Zinc Formalin Levels For Lab Use Only Other___________________ Service Requested (Please Specify Quantity) Serials Unstained Special Stains Specimen Site Accessioning Notes Time 1 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 2 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 3 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 4 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 5 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 6 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 7 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 8 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 9 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 10 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 11 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 12 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 13 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 14 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 15 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 16 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 17 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 18 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 19 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 20 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 21 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue 22 H. Pylori AFB ______________________________________________________________________________ PAS GMS Alcian Blue PAS GMS Alcian Blue H. Pylori AFB 23 Total Number of Blocks: Accessioner Time AM PM Time AM PM NOTE: WHEN ORDERING TESTS FOR WHICH MEDICARE OR MEDI-CAL (MEDICAID) REIMBURSEMENT IS SOUGHT, PHYSICIANS SHOULD ONLY ORDER TESTS THAT ARE MEDICALLY NECESSARY FOR THE DIAGNOSIS OR TREATMENT OF A PATIENT, RATHER THAN FOR SCREENING PURPOSES. LAB COPY
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