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Anatomic Pathology Consultation Request Form

Click on the links below to obtain a downloadable Anatomic Pathology Consultation Request Form. Please note that you will have the option to print and manually complete and fax the form or to complete and submit the form electronically. In addition, we have included a pathology consultation checklist in order to assist you in gathering the documents, materials and reports needed.

It is important that the consultation request form is complete in order to avoid delays in processing.

Attention to referring physician’s name, contributing facility, patient’s demographic and billing information (with copies of insurance cards) is extremely important.

Please enclose the completed form within the package. If the consultation request form is incomplete, the slides will not be reviewed until all needed information is updated and completed. Send the completed form, along with all materials to be reviewed with corresponding pathology report(s) to:

Moffitt Cancer Center
Department of Pathology
ATTN: Outside Consult
12902 Magnolia Drive
MCC – 2nd Floor, RM 2049
Tampa, Florida 33612
Tel: 813-745-3001 • Fax: 813-745-8479

NOTE: Overnight delivery via UPS or Federal Express is preferred.

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