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Get UIDL Renal Clinical History Form

CLINICAL HISTORY Please FAX Clinical History form and Renal Pathology Requisition to Client Services at (319) 384-7213. PLEASE PRINT CLEARLY Referring Nephrologist: Phone: ( ) - Hospital/Clinical Practice: Patient s Name (last, first): Sex: M F DOB: / / Race: W B H Native Biopsy Type: Asian Other Transplant Height: LRTx Weight: LURT ECD BMI P.

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