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Forms to Download

Oral Pathology Patient Form
Oral Pathology Informed Consent
Oral Pathology Mailing Label

Per your office's request, we are sending all the required forms needed to complete a review of your patient's biopsy. We have enclosed the Biopsy Requisition forms, Informed Consent for Treatment and Release of Information forms, Formalin Solution bottles, plastic bags and prepaid return envelopes.

For this to be completed in a timely manner, please make sure to:

Completely fill out and return the Biopsy Requisition form

Submitting Doctor Information

• Doctor's FIRST and LAST name
• Doctor's full address
• Doctor's PHONE and FAX numbers
• Office email address
• Doctor's NPI #

Patient Information

• Patient's FIRST and LAST name
• Patient's full address
• Patient's phone number
• Patient's DATE OF BIRTH
  If the patient is under 18 years of age ...

  Guardians FIRST and LAST name, DOB (if available)
• Patient's SOCIAL SECURITY#

Billing Section

Please specify whether we should we be billing the Patient, Medicare or the Physician
If the patient has Medicare, please include a copy of their Medicare card

Date of Biopsy, Description of Lesion and Clinical Diagnosis

The patient MUST completely fill out. sign and return "Informed Consent for Treatment and Release of Information" form.

The specimen cannot be processed without this signed form.

• 
  Please inform your patients that there will be an ADDITIONAL FEE for tissue reading.
  ** Our office only accepts (State Issued) Medicare.
  *** WE DO NOT ACCEPT ANY OTHER INSURANCE. The patient can submit their bill to their insurance company for reimbursement.

Thank you for your attention to this matter. This will help to expedite the processing of your patient's biopsy and the return of the report to your office.