P A T H O L O G Y • C Y T O P A T H O L O G Y


PSI ACCESSION NUMBER (TO BE COMPLETED BY PSI ONLY)

COLLECTION DATE

PATIENT INFORMATION

BILLING INSTRUCTIONS

If we are billing the patient’s insurance,please attach a copy of the patient’s insurance information to this completed requisition.

PROVIDER INFORMATION

CLINICAL HISTORY / DIAGNOSIS

FOR ALL SPECIMENS SUBMITTED

SOURCE OF TISSUE

NON-GYN CYTOLOGY REQUEST

SOURCE
SPUTUM
BRONCHIAL BRUSHING
BRONCHIAL WASHING
BRONCHOALVEOLAR LAVAGE
BRUSH (site)
FNA (site)
URINE VOIDED
URINE CATHETERIZED
Fluid (site)
Washing (site)
CSF