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Patient Information (Please Print)
MEDICAL DIAGNOSTIC LABORATORIES, 2439 Kuser Road Hamilton, NJ 08690-3303. (609) 570-1000 Fax (609) 245-7665. Toll Free (877) 269-0090. Core OB/GYN Test Requisition Form Ordering Physician/Laboratory Pathology Test Selection (Required: Include the ordering physician's first & last name, NPI, practice name, complete Date Collected (Required): Specimen Source: address, phone number and fax number.). Anatomic Source (Required): Cervix/Endocervix Vagina Vaginal Cuff Other: _____. Date of LMP: Previous Results: ASCUS CIN 1 Other: Normal LGSIL CIN 2. Date of Last Pap: Reactive HGSIL CIN 3. Pathology Test Requisition with completed clinical Information must accompany specimen ThinPrep.
Pathology Test Selection Date Collected (Required): Specimen Source: Anatomic Source (Required): Cervix/Endocervix Vagina Vaginal Cuff Other: _____
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