UMMC Oral Pathology Lab Biopsy Request Form

* - Required Fields

Patient Information
Patient Name*	*
Patient Race*	*
Patient Gender*	*
Date of Birth (MM/DD/YYYY)*	*Invalid Date
Patient SSN*	--******
Patient Address*	*
City/State/Zip*	* 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 * - ***
Home/Cell Number*	() - ******
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*	*
NPI*	*
Phone Number*	() - ******
Address*	*
City/State/Zip*	* 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	() - ***
Number of Biopsy Kits Needed (Multiples of 2)*	*
Specimen Information - Please Remember to Label Specimen Jar
Treatment Date*	*Invalid Date
Biopsy Incisional or Excisional*	*
Location of Lesion*	*
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.