Slide/Block Send-Out Request Form

Patient Name(Required)

Date of Birth(Required)

Case Number(Required)

Number of Slides/Blocks

Person Requesting(Required)

Reason for Sending

Second opinion requested by pathologist

Second opinion requested by patient

Second opinion requested by physician

Requested by outside laboratory

Legal

Correlation of previous biopsy for definitive procedure

Additional material requested

Other

Other Reason

Send to Address

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Signature of Slide Recipient(Required)

Pennsylvania Specialty Pathology