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

Specimen Information - Page 2

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

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

Site / Slide Number:   Collection Date:           CLINICAL FINDINGS  LesionalPerilesionalUninvolved

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