Transcription of PITTSBURGH CYTOGENETICS LABORATORY
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PITTSBURGH CYTOGENETICS LABORATORY
Magee-Womens Hospital of UPMC 300 Halket St., Rm. 1225 (412)641-5558 PHONE (412)641-2255 FAX PITTSBURGH , PA 15213 1/31/2018 SJK PITTSBURGH CYTOGENETICS LABORATORY Constitutional Cytogenetic Study Requisition form PATIENT INFORMATION (Please Print): REFERRING PHYSICIAN (Please Print): Last Name: First: : Name: Address: Home Phone #: Address: City, State, Zip: City, State, Zip: Birthdate: _____ Sex: _____ Male _____ Female SS#(optional): _____ Telephone #: Medical Record #: Account#: Fax #: Send Bill To: _____Insurance (please attach insurance info.) ____ Patient _____ Institution(list): _____ Additional Report To: SPECIMEN INFORMATION: If PRENATAL SPECIMEN, Please Complete: Date/Time of Collection: LMP: Grav.
Magee-Womens Hospital of UPMC 300 Halket St., Rm. 1225 (412)641-5558 PHONE (412)641-2255 FAX Pittsburgh, PA 15213 1/31/2018 SJK PITTSBURGH CYTOGENETICS LABORATORY
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