Histopathology or Non–Gynae Cytopathology Request Form
Histological specimens should be placed in an adequate amount of fixative (at least 10 times as much the volume of the tissue)
APPROX REPORTING TIMES: Histology - Very Urgent (if received by noon) - same day; Urgent 1-2 days, Standard- biopsies and resections 2-7 days
Non-Gynae Cytology - Very Urgent - same day (where possible), Urgent 1-2 days, Standard- 2-7 days
Norfolk and Norwich University Hospital NHS Trust
Norfolk and Waveney Cellular Pathology Network
Surname:
DOB:
Forename(s):
Sex: Male/Female
Address:
Hospital Number:
Post Code:
Clinician/GP:
Request By:
Copy to:
Bleep/ext:
D
M
M
Y
Y
Y
Y
Blocks:
Report Required by:
D
D
M
M
Y
Y
Y
Y
Investigation Required:
Histology Non-Gynae Cytology
Pathologist:
Date & Time of
Collection
D
Address for report:
Received:
NHS
Private
NHS No
Ward:
Lab No: (barcode)
NNUH
JPUH
Spire
Other
H H M M
Previous Specimen Numbers:
Frozen
Tissue bank
IMF Mohs
Specimen (s) (state site if not obvious)
URGENT
HIGH RISK
Clinical Data (nature and duration of symptoms, operative findings, investigations, relevant drug history)
FAILURE TO PROVIDE SUFFICIENT DATA MAY LEAD TO MISDIAGNOSIS & DELAY
Gynae Only
LMP:
D
D
M
M
Y
Y
Y
Y
Recent hormone therapy:
Clinical Diagnosis:
Cancer Reg
MEDRAK
ORDERED
LABTRAK
ORDERED
NEW REPORT
SEARCH
MACRO
TYPED
MICRO TYPED
RECEIPT
ORDER
PREF
STAIN
CHECK
SCREENER
ERROR LOG GENERATED
No Consultant on form
No Location on form
Material on wrong side of slide
Wrong container
Leaking sample
Inadequate fixative
Other
LABORATORY USE ONLY