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PATHOLOGY TESTING REQUEST FORM
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Hospital:
Department:
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Responsible Doctor:
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Attending Doctor:
Patient's MRN:
Patient ID:
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Last Name:
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First Name:
Birthday:
yyyy-MM-dd
Age:
year
month
day
Sex:
Male
Female
Address:
Collection Date:
yyyy-MM-dd hh:mm
Biopsy/Cytology
Gynecological cytology
Tissue Fixation:
10% buffered formalin
Unfixed material
Primary biopsy:
Yes
No
Date, place and registration No. of previous morphological examination:
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CLINICAL DIAGNOSIS:
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Type of surgery:
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Specimen description:
Main clinical notes / Special stains request:
KLINIKINĖ DIAGNOZĖ:
Diagnostic:
Previous PAP:
Unknown
Unsatisfactory
NILM (normal)
ASC-US
LSIL
HSIL
SCC
AIS
ASC-H
AdenoCa
EPM
AGC
Other
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Sample description:
Conventional PAP smear, fixed:
aerosol
ethanol
Liquid based cytology (mark one or several):
PAP
HPV (Detection of 14 high-risk human papillomavirus genotypes (16,18,31,33,35,39,45,51,52,56,58,59,66,68) by real-time PCR)
HPV if ASC in PAP
STI (Detection of 7 sexually transmitted infections causative pathogens – Trichomonas vaginalis (TV), Mycoplasma hominis (MH), Mycoplasma genitalium (MG), Ureaplasma urealyticum (UU), Ureaplasma parvum (UP), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) by real-time PCR)
CINtec PLUS
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Method of sampling:
Brush and spatula
Brush
Other:
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The most important clinical data:
Menstrual cycle day:
Menopause:
Perimenopause
Hormone replacement
Other important information:
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Required fields.