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This requisition form is mandatory to fill for sending the sample.

Online Requisition Form

Date of dispatch of sample/specimen/tissue*

Date of dispatch of sample/specimen/tissue

Patient's Name*

Age*

Gender

Male
Female
Prefer Not to Say

Occupation*

Patient's Phone Number

Patient's Address

Biopsy Type

Incisional
Excisional
FNAC
Cytology Smear

Clinical Details*

Habit history

Medical history

Family history

X-ray

Scan

Any other

Provisional diagnosis*

Referred by

Name*

Clinic/Hospital

Phone Number*

Email*

Special Instructions

Note for clinicians/ surgeons

1. Kindly state the minimum personal details of the patient. It is mandatory. 2. Please furnish clinical and imaging details (soft copy). 3. Please store the tissue biopsy in 10% formalin. (Containers and vials are available with us). 4. Tag or mark the margins and/or areas of interest of the specimen submitted. It will be reported accordingly. 5. We also undertake special stains and marker analysis. 6. In case of FNAC or cytology- we can furnish the required paraphernalia. 7. Routine H & E slide with report- 5 days. Large specimen and hard tissue specimen- require 7 days to report. 8. Report can be provided as Hard copy or soft copy as preferred.

I/We have read the instructions properly and confirm that the information given hereis true to the best of my/our knowledge.

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