Top of Page
Skip main navigation

Information and Forms

All the required forms (listed below) will be needed to complete a review of your patient's biopsy.

In order 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
• 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)

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

Completely fill out. sign and return "Informed Consent for Treatment and Release of Information" form. The specimen cannot be processed without this signed form.

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.

* 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.

Forms to Download

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

Return to top of page