University of Colorado Dermatopathology Consultants

Physical Address:

University of Colorado Dermatopathology Consultants
1665 N. Ursula Street
ACP Building, 3rd Floor, Room 3247
Aurora, CO 80010

Mailing Address:

University of Colorado Dermatopathology Consultants
P.O. Box 6510
Mail Stop F703
Aurora, CO 80045-0510
Dermatoimmunologists
James E. Fitzpatrick, M.D.
Whitney A. High, M.D.
Marti Friednash, M.D.
Anwell Chang, M.D.
Lori Prok, M.D.


Contact Information
Phone: 720-848-0535
Fax: 720-848-0591


Patient Information:
Last Name: First Name:
Home Phone: DOB: Sex:
Address 1: Address 2 / Suite:
City: State: Zip Code:
Payor:
Practice Information:
Practice Name:
Contact Name:
Address 1:
Address 2 / Suite:
Phone:
City: State: Zip Code:
Referring Physician Name:
Copy To:
(Name, Address, Fax, Phone)
Insurance Information: Attach a copy of front and back of insurance card or face sheet
HMO Insurance Authorization #:  Date of Service
Specimen Information
Specimen A:

 


Site / Slide Num:   CollectionDate: 

CLINICAL FINDINGS 
 
CLINICAL PHOTOS

ICD-9 Code(s)
1.
2.
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