Oral Pathology

Main Content

UMMC Oral Pathology Lab Biopsy Request Form

CONTENT HERE

* - Required Fields

Patient Information
Patient Name*
Patient Race*
Patient Gender*
Date of Birth (MM/DD/YYYY)*
Patient SSN*
Patient Address*
City/State/Zip*

  -

Home/Cell Number*

Billing Information
Billing To:*  

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.

NO medical insurance, patient has been informed of separate pathology fee.
Physician's office or other facility information

Dental Provider Information
Doctor Name*
NPI*
Phone Number*
Address*
City/State/Zip*

  -

Fax
Number of Biopsy Kits Needed (Multiples of 2)*

Specimen Information - Please Remember to Label Specimen Jar
Treatment Date*
Biopsy Incisional or Excisional*
Location of Lesion*
Lesion Size*
Clinical History*
Appearance/Consistency*
Radiographic Appearance*
Clinical Diagnosis*
Upload any document here.
Upload any photo here.
Additional clinical photos, X-rays or information may be emailed to oralpath@umc.edu.