CORONERS ACT, 1975 AS AMENDED
Mohs Case #_____ Mohs Surgeon_____ Surgery Date_____ ... (lower extremity site, groin, mucosal) Long duration of procedure Patient History of wound infection. Routine practice Other (Specify)_____ ... muscle or bone Breslow depth >2mm Palpable lymph node Occurring in a prior radiation field High risk tumor (Go to additional work-up) ... ................
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