DERMATOIMMUNOLOGY

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

Specimen Information - Page 2

IMPORTANT! List any potentially infectious conditions the patient may have or be suspected to have

Specimen B: Direct Immunofluorescence Stain/Stains (DIF) Indirect Immunofluorescence Stain/Stains (IIF) Immunomapping Split Skin

Site:  Collection Date:     CLINICAL FINDINGS  LesionalPerilesionalUninvolved

CLINICAL PHOTOS Enclosed with Specimen Sent Digitally ICD-9 Code(s) 1. 2.