|
|
Requisition Form, GenoPath
( 美国基因病理诊断和谘询公司会诊申请单 |
|
Pt’s Name: 病人姓名: |
Sex: 性别: |
Date of Birth or Age: 出生日期或年龄: |
|
|
Referred by ( ) Physician, ( ) Patient or ( ) Others 会诊申请人：医生 ( )，病人 ( ), 其他人 ( ). |
Date of Referral: 送诊日期: |
||
|
Consultation Report to Be Sent to (Name and Address) 会诊申请人姓名和地址: Tel. 电话: Fax 传真: E-mail 电邮: |
|||
|
Preferred Method to Receive the Final Report 请选择接收会诊报告方式:
( ) Mail 邮寄, ( ) Telephone 电话, ( ) Fax 传真, ( ) E-mail 电邮. |
|||
|
Clinical History 临床病史 History of present illness现病史:
Past history 过去史:
Important family and social history (smoking, etc.) 相关家族史和生活史(如吸烟等): |
|||
|
Preliminary Pathologic Diagnosis 初步病理诊断或印象:
(Important: original
pathology report should be included for each consultation 注意:会诊申请单务请附上原始病理报告) |
|||
|
Main Question(s) to Be Addressed and Purpose for Consultation 会诊主要问题和目的:
|
|||
|
Materials Submitted for Consultation 送诊标本和片子 Slides (number) 切片 _________ 张; No. 编号_______________________________________________________ Blocks (number) 石蜡包块_________ 张; No. 编号__________________________________________________ X-Rays (number) X光片__________ 张; Other 其它: |
|||
|
Payment Method (please check) 请选择付费方式 ( ) Cash 现金 ( ) Check支票 ( ) Credit card 信用卡 ( ) Money order 汇款或汇票 ( ) Health insurance (Require pre-arrangement) 医疗保险(需事先安排) (
) Other method 其它方式 |
|||
Mailing Address 邮寄地址: 北京市石景山区京原路5号北京朝阳医院(京西院区)基因病理诊断中心, 邮编:100043,
电话:010-51718025,8075,8015; 美国: GenoPath (