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Tissue Consultation Request Form

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Tissue Consultation Request Form

Fill out the online form below and click “Submit” to send electronically to our office.

Additional Resources:

Click HERE for downloadable PDF of the online form

Tissue Consultation Request Form

Step 1 of 3

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Contact Information
Today's Date*
MM
DD
YYYY
Agency*
Referring Physician*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Enter Email Confirm Email

Case Information
Client Case Number*
Put "none" if no case number
Name of Decedent*
First Last
Date of Birth*
MM
DD
YYYY
Date of Death*
MM
DD
YYYY
Date of Autopsy*
MM
DD
YYYY
Sex*
Race

Specimen(s) Submitted
Specimen(s) Submitted*
- Dura Matter
- Brain
- Spinal cord
- Cervical Spine
- Peripheral muscle
- Peripheral nerve
- Right globe
- Left globe
- Heart
- Heart and lungs
- Aorta/vessels
- Pelvic exenteration
- Bone (list below)
- Other (list below)
check all that are relevant
Other Materials Submitted for Review
(documents, photographs, radiographs, advanced imaging, etc.) Please separate materials by commas or new lines
Circumstances of Death*
Relevant Clinical, Historical and Investigative Findings*
Summary of Autopsy Findings Including Presumed Cause and Manner of Death*
Specific Questions for Consultation*

MAILING ADDRESSES

6540 Lusk Blvd

Suite c262

San Diego, CA 92121

Business Hours

Our support Hotline is available between 8am-4pm Monday-Friday: (800) 985-5346

Monday-Friday: 8am to 4pm
Saturday: Closed
Sunday: Closed

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