CYTOLOGY REQUISITION
Requesting Location
Collection Data
Submitting Location
Name
Attending Physician
IDX MRN #
DOB
Diagnosis Code
GYN PAP
SPECIMEN SOURCE: (CHECK ALL THAT APPLY)
Vagina Wall
Cervix
Endocervix
Other
PAP TEST: (CHECK ALL THAT APPLY)
88175 IMAGE ASSISTED THINPREP PAP
88142 NON-IMAGE ASSISTED THINPREP PAP
88164 CONVENTIONAL PAP SMEAR
ANCILLARY TEST: (CHECK ALL THAT APPLY)
87621 HIGH RISK HPV
87621 REFLEX HIGH RISK HPV - ASCUS DIAGNOSIS ONLY
87661 T. VAGINALIS
87591 N. GONORRHOEAE
87491 C. TRACHOMATIS
CLINICAL INFORMATION: (CHECK ALL THAT APPLY)
v72.31 ANNUAL EXAM
V76.2 ROUTINE PAP SMEAR
MENSTRUAL STATUS: LMP (REQUIRED)
PREGNANT
POSTPARTUM
IUD
POSTMENOPAUSAL
HYSTERECTOMY
BIRTH CONTROL
HORMONE THERAPY:
RADIATION THERAPY:
CHEMOTHERAPY:
PREVIOUS ABNORMAL PAP/BIOPSY:
PREVIOUS CANCER DIAGNOSIS:
OTHER HISTORY/SYMPTOMS:
NON GYN / FNA
RESPIRATORY
SPUTUM
BRONCHIAL BRUSH
BRONCHIAL LAVAGE
BRONCHIAL WASH
FLUIDS
PERICARDIAL FLUID
PERITONEAL FLUID
PERITONEAL WASH
PLEURAL FLUID
URINE
BLADDER (CATHERIZED)
BLADDER (VOIDED)
BLADDER (WASH)
RENAL PELVIS
GASTROINTESTINAL TRACT
ESOPHAGEAL BRUSH
GASTRIC BRUSH
CENTRAL NERVOUS SYSTEM
CEREBROSPINAL FLUID
OTHER: SPECIFY SOURCE(S)
FINE NEEDLE ASPIRATION (FNA): SPECIFY SOURCE(S)
PATIENT HISTORY
OPERATIVE PROCEDURE:
OPERATIVE FINDINGS:
POST-OP DIAGNOSIS:
Submit
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