tel: +44 (0)20 3912 0280 | email: @hslpathology.com web: a ... · i c s ihc / ish request form tel:...
TRANSCRIPT
H E A L T H S E R V I C E SL A B O R A T O R I E SA D V A N C E D D I A G N O S T I C S
IHC / ISH REQUEST FORMTel: +44 (0)20 3912 0280 | Email: [email protected] | Web: www.hsl-ad.com
HSL-AD, Ground Floor, 60 Whitfield Street, London, W1T 4EU | Version Number: HSL-AD MF1 v1.4
ANTIBODIES / ISH PROBES REQUESTED
REFERRAL DETAILS
INVOICING DETAILS (If different from above)
PATIENT DETAILS IQC INITIALS LAB USE ONLY
CHARGE
SURNAME:
FORENAME:
DATE OF BIRTH:
SURGICAL NO:
TISSUE TYPE:
CLINICAL DETAILS:
HOSPITAL:
PATHOLOGIST:
CUT
LABELLED
COLLATED
QC
PACKAGED
HSL-AD NO:
DATE RECEIVED & INITIALS:
BLOCK/SLIDES:
DATE REQUESTED:
FM