Specimen Referral Form For Native Biopsies - Unc Nephropathology

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UNC DIVISION OF NEPHROPATHOLOGY
RENAL BIOPSY SPECIMEN REFERRAL FORM
—For Native Kidneys Only—
Send this referral form with tissue to:
UNC Division of Nephropathology
Telephone: (919) 966-2421
409 Brinkhous-Bullitt Bldg.
Fax: (919) 966-4542
Department of Pathology CB#7525
UNC School of Medicine
Downloadable forms and further instructions can be
Chapel Hill, NC 27599-7525
found at our website:
REFERRING HOSPITAL/INSTITUTION
REFERRING PHYSICIAN
Nephrologist:
Pathologist:
Address:
Hospital:
Address:
Phone:
FAX:
Phone:
Email:
FAX:
PATIENT INFORMATION
Biopsy Description: ___________
____________ ________________
(length)
Formalin
Michel's
Glutaraldehyde
DATE OF BIOPSY:_________________
The patient is (please circle one): Inpatient / Outpatient
Name:
_________________________
________________________
_______________________
(Last name)
(First name)
(Middle name or initial)
Race:__________
Sex: male / female
Date of birth:________________
Age:_____
Is this a transplant?
Yes
No
(If yes, please use transplant referral form)
History and Clinical Diagnosis
Diabetes Mellitus (Y/N) Obesity (Y/N) Malignancies (Y/N) Hypertension (Y/N) SLE (Y/N) Infection (Y/N)
Symptoms and Signs
Blood Pressure:___________
__ Edema ___ Arthritis/Arthralgias ___ Skin Lesions
Other:
Laboratory Data
Urine
Sediment:
Red blood cell casts?
Other casts (specify)?
Hematuria?
Proteinuria?
______gm/24 hr Proteinuria
Other:
______ UPC ratio
Serum
Creatinine:
BUN:
Creatinine Clearance:
Albumin:
Glucose:
HbAlc:
Complement:
Cholesterol:
ASO:
ANA:
Anti-DNA:
ANCA:
MPO ANCA?
PR3 ANCA?
HepB INF:
HepC INF:
Other: ___________________
Previous renal biopsies:
Therapy:
Revised 11/23/2011 JRM

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