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Partner with us
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Pathology Materials
Request

As a courtesy, original materials (slides or blocks) may be sent out to another healthcare facility upon request for the purpose of continuation of patient care. It is the responsibility of the requester and/or receiving facility to communicate to the patient any applicable charges for their intended services, as well as to verify insurance coverage eligibility for such services.

Request for materials to be sent to a testing facility for patient care

Please complete this 4 step form to submit your request. Shipping costs will also be the responsibility of the requester or receiving facility. Please have your FedEx or UPS shipping account number available when submitting requests.

Step 1

Requestor / Contact Person Information
First Name*
Last Name*
Email*
Phone*
Date of request*
MM slash DD slash YYYY
Purpose of request*

Request for materials to be sent to a testing facility for patient care

Please complete this 4 step form to submit your request. Shipping costs will also be the responsibility of the requester or receiving facility. Please have your FedEx or UPS shipping account number available when submitting requests.

Step 2

Patient Information
Patient First Name*
Patient Last Name*
Date of birth*
MM slash DD slash YYYY
City of residence*
State of residence*
Date or timeframe of biopsy / tissue sample*
MM slash DD slash YYYY
to*
MM slash DD slash YYYY
Biopsy or tissue sample body site location (if more than one sample taken)*

Request for materials to be sent to a testing facility for patient care

Please complete this 4 step form to submit your request.

Step 3

Requested Materials & Testing Facility Information
Please select one:*
- Slides
- Unstained Slides(s)
Specify # of unstained slides needed
- Pathology Report(s)
Intended Test(s):
Name of testing facility to receive materials:*
Ship to: First name*
Last name*
Address*
Ship to: Street address 1* Ship to: Street address 2* City* State* Zip Code*
Shipping cost payment method (select one):*
- Bill to my FedEx account number:
- Bill to my UPS account number:
- Upload a FedEx or UPS pre-paid shipping label
- Call Me to Pay $50 via Çredit Card
Fedex account number*
UPS account number*
Upload a FedEx or UPS pre-paid shipping label*
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 25 MB.
Amount paid for processing and shipping (no additional payment required)*

Request for materials to be sent to a testing facility for patient care

Please complete this 4 step form to submit your request.

Step 4

Requester Acknowledgements
Please check all 3 boxes*
- I certify that I am involved in this patient’s treatment and need pathology materials for treatment purposes.
- I agree to return the original materials intact within 30 days along with a copy of diagnostic report generated to:
  Forefront Dermatology, S.C.
  Attn: 4th floor Pathology
  801 York St.
  Manitowoc, WI 54220
  Report may be included with the returned original materials or e-mailed to [email protected]
- I understand that it is the responsibility of the requestor and/or receiving facility to communicate to the patient any applicable charges for the intended services as well as to verify insurance coverage eligibility for such services.
Additional comments:
Electronic signature*
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