DERMATOIMMUNOLOGY ELISA TESTING

University of Colorado Dermatopathology Consultants Physical Address: University of Colorado Dermatopathology Consultants 1999 N. Fitzsimons Parkway Bioscience East, Suite 120 Aurora, CO 80045 Mailing Address: University of Colorado Dermatopathology Consultants 1999 N. Fitzsimons Parkway Bioscience East, Suite 120 Aurora, CO 80045

Dermatoimmunologists James E. Fitzpatrick, M.D. J. Clark Huff, M.D. Contact Information Phone: 303-344-1022 Fax: 303-344-0789 Please review form after printing

Patient Information:

Last Name:

First Name:

Home Phone:

DOB:

Sex:

Address 1:

Address 2 / Suite:

City:

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Zip Code:

Payor:

Patient

Insurance

Client

Other (explain)

Practice Information:

Practice Name:
Contact Name:
Address 1:
Address 2 / Suite:

Phone:

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Zip Code:

Referring Physician Name:

Copy To: (Name, Address, Fax, Phone)

Insurance Information: Attach a copy of front and back of insurance card or face sheet

HMO Insurance Authorization #:

Date of Service

ELISA Specimen Information

IMPORTANT! List any potentially infectious conditions the patient may have or be suspected to have Please use only one form per patient

ELISA Study A: Desmoglein 1 & 3 (DSG 1/3) BP 230 & 180 Clinical Photos: Enclosed with Specimen Sent Digitally

Site:  Collection Date:     CLINICAL FINDINGS

SENT Direct IF Indirect IF ICD-9 Code(s) 1. 2.

Additional Specimens? Click Here