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Get Brigham And Women's Hospital Patient Slide Consultation Request Form

For the consultation and results can also be released to the p atient and designees, as listed below. Additionally, our o ffice acknowledges that the p atient is solely responsible for the consultation charges and should be billed accordingly. This form must be accompanied with a billing guarantor form that has been completed by the patient. Please send *Slides/Blocks *Pathology Report *Completed form *Attach insurance/demographic information Patient Information: Name: Gender (Please circle.

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