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Pathology Department - PL
Phone: 612-873-3079
701 Park Avenue
Fax: 612-904-4629
Minneapolis, MN 55415-1829
Pager: 612-223-6602

Renal Biopsy Interpretation Request

 

HCMC Accession # _____________________


 
PATIENT INFORMATION
 
Gender*
BILLING AND INSURANCE INFORMATION
SUBMITTING INSTITUTION
PHYSICIAN INFORMATION

Call Results to:

Fax Results to:

SPECIMEN INFORMATION
 
TEST REQUESTED
mm
mm
mm
CLINICAL INFORMATION
 

Indication for Biopsy:*

Urinalysis/Urine Tests:

Urinalysis/Urine Tests: