Intra-Operative Neuropathology Consultation Requisition Form

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INTRA-OPERATIVE NEUROPATHOLOGY CONSULTATION
 ACH
 FMC
 SHC
*
REQUIRED INFORMATION
PROCEDURE PERFORMED IN:
 OR: ________________  CLINIC: ________________  OTHER: ______________
PHYSICIAN TO ACT ON RESULTS:
_______________________________
_________________________________
*
Last Name
*
Full First Name
____________________________________________________________________
Address (Location Code) for Report Delivery
*
Report to be  PHONED to: ________________________________
Number
Report to be  FAXED
to: ________________________________
Number
*
Affix addressograph imprint or patient label to ALL PAGES or clearly print patient’s full name (last name,
*
full first name), date of birth, gender, Personal Health Number, and Regional Health Record Number.
TISSUE REMOVED BY:
SAME PERSON/LOCATION AS ABOVE
DATE COLLECTED:
ACCESSION NUMBER (Lab Use Only)
_______________________________ __________________________________
Last Name
Full First Name
___ ___ ___ ____ / ___ ___ ___ / ___ ___
Y
Y
Y
Y
M
M
M
D
D
____________________________________________________________________
Address (Location Code) for Report Delivery
ADDITIONAL COPIES TO:
1) _____________________________
__________________________
____________________________________________
*
Last Name
*
Full First Name
*
Address (Location Code) for Report Delivery
2) _____________________________
__________________________
____________________________________________
Last Name
Full First Name
Address (Location Code) for Report Delivery
*
*
*
FROZEN SECTION
SPECIMEN (e.g. A. B. C)
Clinical Information (History & Neurological Examination):
Previous Therapy: (Circle)
Radiotherapy
Chemotherapy
Surgery
Year:
Year:
Year:
CT/MRI Findings:
(circle)
* Specimen Submitted:
Side:
RIGHT
LEFT
Intra Axial
Extra Axial
Location: Frontal
Parietal
Temporal
Occipital
Cerebellum
Brainstem
Spinal cord
Spine
Other:
Intraoperative Neuropathological Diagnosis:
(Neuropathology use only below this line)
Pathologist: ________________________________
______________________________
Print Name
Signature
Label Name:
Cassette Number:
Gross Description
Label Designation:
Size: ______ x ______ x ______ cm / ______ grams
Appearance: white / tan / gray / pink / yellow / red / burgundy / brown / black / ___________________________________
Number of fragments: __________
Texture: myxoid / soft / firm / friable / rubbery / hard / mineralized / cauterized / __________________________________
Additional Description:
Disposition: Portions / Entirely submitted for:
 Intraoperative smear / frozen section
 Cytogenetics
 Electron microscopy
 Brain tissue bank, per protocol
 Storage at -80 C
 No sections submitted
Block ______, frozen section remnant
Block ______ to ______; ________________________________________________________________ , entirely / representative sections / _____% submitted
Laboratory Information Centre: 403-770-3600
REQ9034AP
20151218

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