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Flow Cytometry Request
Please fill out each section completely.
Patient information
Name:
MRI #: Location:
Physician: Pathologist:
Interpreting Pathologist:
State relevant clinical findings:
Speciment Information:
Date of Collection: / /
Speciment Type: (Blood, Bone Marrow, Ascites Fluid, Bronch Lavage, CSF, Pleural Fluid or Tissue)
Flow Cytometry Panels:
← Acute Leukemia
← Unclassified Leukemia
← Lymphoid Leukemia
← Myeloid Leukemia
← Lymphoproliferative Disorders (Lymphone/CLL)
← Multiple Myeloma
← MDS
← Other
Pathology Case #:
Cytology Case #:
RUN HOLD
Was sample in formalin?
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