Fill in the Fillable Requisition Form [PDF] on your computer and then print. If you have additional information that you would like to include with the requisition, please print it on a separate piece of paper and attach it to the requisition.
All specimens should be accompanied by a requisition form.

Pathology Requisition

AAD LAB_Form

Dermatopathology Requisition

Requisition Information:

A single patient requisition is used for up to 6 specimen sites. Once completed, it must be placed in one of the poly bags associated with the specimen containers/case.

If more than 6 specimens are submitted for one patient, two separate requisitions must be completed.

The following information must be provided in a legible format:

Patient Information:

  • Patient’s first and last name
  • Date of Birth (DOB)
  • Gender of patient
  • Health Care Provider Information:
    * Full name, address and billing number of the ordering health care provider
  • ICD-9 Code
  • Collection Date and Time
  • Physician Name
  • Type of specimen (body site)