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Get Colposcopy Reporting Format

OMEN S CLINIC USE ONLY VGH Women s Clinic Gordon and Leslie Diamond Health Care Centre 6th Floor - 2775 Laurel Street, Vancouver PATIENT DETAILS Name: Address: Date of Birth: Telephone Home: Work: Referring MD Name: Billing #: Referring MD Telephone: Fax: PHN #: Cytology Lab ID Number: Patient referred for: assessment only assessment and management Was Colposcopy recommended by BCCA?: Yes No If yes, FAX CYTOLOGY REPORT WITH THIS FORM PATIENT HISTORY REASON FO.

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