Pathology Consultation Request

Even if you are not able to travel to New York City for an appointment, you can still receive the medical opinion of one of MSK’s world-class pathologists.

To help us assess your case, please use the form below or call 212-639-6780 Monday through Friday 9am to 5pm ET.

Relationship

I am a:

Patient

Referring Physician

Enter Physician’s Information

First Name

Last Name

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Fax

Speciality

National Provider Identifier

Enter Patient’s Personal Information

First Name

Last Name

Gender

Date of Birth

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Enter Patient’s Medical Information

Patient Medical

Site of Lesion

Consult Requested by

Patient's Clinical History

Reason for Consultation & Specific Questions

Working or Differential Diagnosis

Materials for Review

The items below are not required. If you do have this information, please enter it below.

Slides
Path Number	# of slides	Check if MSK can retain slide
Slide 1 - Path Number	Slide 1 - Number of slides	Slide 1 - Retain slides
Slide 2 - Path Number	Slide 2 - Number of slides	Slide 2 - Retain slides
Slide 3 - Path Number	Slide 3 - Number of slides	Slide 3 - Retain slides
Slide 4 - Path Number	Slide 4 - Number of slides	Slide 4 - Retain slides

Blocks
Path Number	# of blocks	Check if MSK can retain block
Block 1 - Path Number	Block 1 - Number of blocks	Block 1 - Retain blocks
Block 2 - Path Number	Block 2 - Number of blocks	Block 2 - Retain blocks
Block 3 - Path Number	Block 3 - Number of blocks	Block 3 - Retain blocks
Block 4 - Path Number	Block 4 - Number of blocks	Block 4 - Retain blocks

Other	Check if MSK can retain other
Other 1 - Path Number	Other 1 - Retain other
Other 2 - Path Number	Other 2 - Retain other

Relationship

Enter Physician’s Information

Enter Patient’s Personal Information

Enter Patient’s Medical Information

Patient Medical

Materials for Review

Billing Information

Billing

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