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UserID: 35.173.57.202   2019-09-16      PATHOLOGY TESTING REQUEST FORM 
Hospital:
Department:
Responsible Doctor:            E-mail.:  Tel.: 
Attending Doctor:            E-mail.:  Tel.: 

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Patient's MRN: Patient ID:
Last Name: First Name:
Birthday:   Age: year  month  day  Sex  : 
Address:

Collection Date: yyyy-MM-dd hh:mm Snomed code:
Tissue Fixation:
Primary biopsy:

Date, place and registration No. of previous morphological examination:
CLINICAL DIAGNOSIS:
Type of surgery:
Specimen description:
Main clinical notes: