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University of Missouri Dermatopathology Kara Braudis, MD Laboratory Director Emily Smith, MD SUBMITTING CLINICIAN: (PLEASE PRINT) PATIENT INFORMATION - REQUIRED NAME (FIRST) (LAST) DATE OF BIRTH GENDER PATIENT ADDRESS (NO PO BOX) CITY, STATE, ZIP CODE PHONE NUMBER 1020 Hitt Street, Rm 2216 Columbia, MO 65212 TEL: 573-884-0123 FAX: 573-884-0834 Website: http:// Email: mudermpath@health.missouri.edu SEND COPIES TO: (PLEASE INCLUDE ADDRESS, PHONE AND FAX NO.) DATE OF SERVICE: YOUR PATIENT MRN: PLACE OF SERVICE: (PLEASE CHECK ONE) BILLING INFORMATION: (PLEASE CHECK ONE) (USE EXTRA SHEETS FOR ADDITIONAL SPECIMENS) CLINICAL FINDINGS: SPECIMEN B: BODY SITE: CLINICAL FINDINGS: BODY SITE: SPECIMEN C: D CLINICAL FINDINGS: SPECIMEN A: BODY SITE: Male Female Other Punch Punch Excision Alopecia Sections Slide Consult Direct IF (Skin) Nail Clippings Shave Incision Excision Alopecia Sections Slide Consult Direct IF (Skin) Nail Clippings Shave Incision Punch Excision Shave Incision Clinician Office (11) Hospital Inpatient (21) Name Hospital Outpatient (22) Name Other Bill Insurance (Attach copy of card) Bill Patient Bill Other (Attach information) Alopecia Sections Slide Consult Direct IF (Skin) Nail Clippings
