University of Colorado Dermatopathology Consultants

Physical Address:

University of Colorado Dermatopathology Consultants
1999 N. Fitzsimons Parkway
Bioscience East, Suite 120
Aurora, CO 80045

Mailing Address:

University of Colorado Dermatopathology Consultants
1999 N. Fitzsimons Parkway
Bioscience East, Suite 120
Mail Stop B118
Aurora, CO 80045
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: 303-344-1022
Fax: 303-344-0789


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:

 


CollectionDate:
Site:
Slide Num:
CINICAL FINDINGS
CLINICAL PHOTOS

ICD-9 Code(s)
1.
2.

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