CHOP Pathology Core
Submission Request Form
General Information
PI Name
MUST BE FULL NAME " John Smith" - NO MIDDLE INITIALS - NO PREFIX - NO LAST NAME ONLY (i.e. Smith)
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PI Account
Account must be pre-registered in the the CHOP billing system
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Delivered By
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Phone
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Email
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Specimen Data
Collection Date
Please enter date of specimen collection
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Fixation
Enter type of fixation (e.g. formalin)
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Fixation Time
How long has specimen been in fixative
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Species
If Human, enter IRB protocol number below
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IRB Protocol #
For Human Samples
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Tissue Type
Identify the sample organ(s)
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Specimen Identification
Please enter specimen identifiers separated by commas. For human samples do not use patient identifiers (names, birthdate, medical record numbers, etc.)
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Total # of Specimens
Please enter total number of samples ( ie: 36 blocks)
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Service #1
For external (Not CHOP/UPENN) academic researchers add 10% to posted rate. Commercial rate is 2X the posted subsidized rates.
Service 1
Please Choose First Service
Service 1 Quantity
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Service 1 Comment
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Service 1 Rush
Service #2
Service 2
Please Choose Second Service
Service 2 Quantity
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Service 2 Comment
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Service 2 Rush
Service #3
Service 3
Please Choose Third Service
Service 3 Quantity
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Service 3 Comment
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Service 3 Rush
Service #4
Service 4
Please Choose Fouth Service
Service 4 Quantity
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Service 4 Comment
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Service 4 Rush
Service #5
Service 5
Please Choose First Service
Service 5 Quantity
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Service 5 Comment
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Service 5 Rush
Comments/Instructions
Comments
Please include any special instructions/information here
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