Telemedicine Pathology Assessment Form
Use this form to submit a telemedicine pathology case for review and assessment.
Patient and Case Information
Patient Name or Reference
*
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex/Gender
Please Select
Female
Male
Intersex
Non-binary
Prefer to self-describe
Prefer not to say
Referring Clinician Name
*
First Name
Middle Name
Last Name
Referring Facility/Clinic
*
Specimen/Case ID
*
Date of Specimen Collection or Referral
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pathology Assessment Details
Pathology Specimen Type
*
Biopsy
Cytology
Surgical Specimen
Blood Smear
Other
Clinical Question or Reason for Consult
*
Relevant History
Key Morphologic Findings
*
Diagnostic Impression
*
Confidence Level / Certainty
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Severity and Follow-up
Urgency Level
*
Routine
Urgent
Critical
Recommended Follow-up Action
*
Please Select
Repeat review
Additional stains/tests
In-person evaluation
Specialist referral
Routine monitoring
Other
Additional Comments or Limitations of Telemedicine Review
Submit Assessment
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