DERMATOIMMUNOLOGY

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. J. Clark Huff, M.D. Contact Information Phone: 720-848-0535 Fax: 720-848-0591 Please review form after printing

Patient Information:

Last Name:

First Name:

Home Phone:

DOB:

Sex:

Address 1:

Address 2 / Suite:

City:

State:

Zip Code:

Payor:

Patient

Insurance

Client

Other

Practice Information:

Practice Name:
Contact Name:
Address 1:
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Phone:

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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

IMPORTANT! List any potentially infectious conditions the patient may have or be suspected to have

Specimen A: Direct Immunofluorescence Stain/Stains (DIF) Indirect Immunofluorescence Stain/Stains (IIF) Immunomapping Split Skin

Site:                          Collection Date:     CLINICAL FINDINGS  LesionalPerilesionalUninvolved

CLINICAL PHOTOS Enclosed with Specimen Sent Digitally ICD-9 Code(s) 1. 2.

Additional Specimens? Click Here