DERMATOIMMUNOLOGY

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. J. Clark Huff, M.D. Whitney A. High, M.D. Lori Prok, M.D. Contact Information Phone: 303-344-1022 Fax: 303-344-0789 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 (explain)

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

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