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Oral-Maxillofacial Surgery and Pathology
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Main Content
UMMC Oral Pathology Lab Biopsy Request Form
CONTENT HERE
*
- Required Fields
Patient Information
Patient Name
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Patient Race
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Patient Gender
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Date of Birth (MM/DD/YYYY)
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Invalid Date
Patient SSN
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Patient Address
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City/State/Zip
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*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Home/Cell Number
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Billing Information
Billing To:
*
Medical Insurance
Patient
Physicians office or other facility
*
Attach copies of insurance cards & subscriber name, DOB & SSN if other than patient.
Subscriber name, DOB & SSN if other than patient
Upload any attachment here.
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
NO medical insurance, patient has been informed of separate pathology fee.
Physician's office or other facility information
Dental Provider Information
Doctor Name
*
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NPI
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Phone Number
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Address
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City/State/Zip
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
*
-
*
*
*
Fax
(
)
-
*
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Number of Biopsy Kits Needed (Multiples of 2)
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Specimen Information - Please Remember to Label Specimen Jar
Treatment Date
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*
Invalid Date
Biopsy Incisional or Excisional
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*
Location of Lesion
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*
Lesion Size
*
*
Clinical History
*
*
Appearance/Consistency
*
*
Radiographic Appearance
*
*
Clinical Diagnosis
*
*
Upload any document here.
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
Upload any photo here.
*.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff
Additional clinical photos, X-rays or information may be emailed to
oralpath@umc.edu
.