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VUMC Neuropathology
1161 21st Ave. South
C-2318 MCN
Nashville, TN 37232-2561
Phone: 615-322-3998
Fax: 615-343-7089
1. Patient Information: (please print) Required
Last Name: ______________________________ First Name:_______________________ MI:____
SS#:______________________ Date of Birth:_______________________ Sex:______________
2. Billing Information: Required
Bill To:
Patient Insurance (must attach demographics) ☐ Client/Institution
3. Clinical Information: Required
-Complete this section AND attach clinical notes
Clinical diagnosis/brief medical history/EMG/NCS Results:
4. Ordering Physician/Sending Institution: Required
Institution Name:__________________________________Address:_________________________
_______________________________________________________________________________
Contact Person:(who filled out this form)___________________________Phone: ________________
Physician Name:_________________________________________________
Phone:____________________ Fax:___________________
Referring Pathologist Name: (if applicable)____________________________________
Phone:____________________ Fax:___________________
Fax number for results to be sent: Required (__________) ___________________________
5. Specimen Information: Required
ICD10 CODE(s)__________________
1st: Muscle__ Nerve__
Site:__________________________________________ Right or Left
2nd: Muscle__ Nerve__
Site:__________________________________________ Right or Left
Specimen Types Enclosed:
Fresh unfixed tissue
Frozen tissue for muscle workup
Formalin fixed (not for nerves)
Glutaraldehyde (2% for muscles)
Frozen muscle for metabolic studies
Glutaraldehyde
(4% for nerve only)
The purpose of this form is to obtain information necessary for the Neuropathology Department to perform consultations
Glutaraldehyde (2% for muscles) and/or testing. Failure to properly complete the form may cause delay in the processing of specimens. Revised 12-2015
Frozen muscle for metabolic studies