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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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