Molecular Pathology Request Forms

Download our molecular pathology request forms in the downloads section below.

Please complete request forms electronically whenever possible. This reduces transcription errors and helps ensure patient information is accurate.

When completing a request form:

• complete all sections
• provide relevant clinical information
• clearly identify urgent or priority cases
• use block capitals if completing the form by hand

Incomplete forms may delay testing.

Specimen requirements

Patient identification stickers can be used. Please use the full patient identification label rather than blood tube stickers.

All specimens must meet the laboratory's minimum data requirements. We may return specimens that do not contain sufficient information.

Please include:

• relevant clinical history
• priority or urgent status, where applicable
• a copy of the pathology report where available

Shipping requirements

The sender is responsible for arranging safe packaging and transport of specimens in line with national and international regulations.

If sending multiple patient samples in one package:

• package each patient's specimen separately
• attach the correct referral form to each specimen
• keep tissue blocks from different patients separate

Sending specimens from external organisations

Referring organisations are responsible for arranging transport to MPDS.

We recommend using a tracked or recorded delivery service. Queen Elizabeth Hospital Birmingham (QEHB) cannot accept responsibility for specimens lost in transit.

Sending specimens from UHB

Departments within UHB are responsible for arranging transport to MPDS.

Samples can be:

• sent through the internal post system
• hand delivered

If you deliver a sample to the CLS specimen reception, please contact Molecular Specimen Reception on ext. 13325 to let us know it has arrived.

Hazardous specimens

Clearly identify specimens from patients with known or suspected infectious diseases, including:

• tuberculosis
• viral hepatitis
• HIV

Please package these specimens appropriately to protect staff handling them.

Downloads

Abbvie FOLR 1 IHC (1.22 MB)

Breast Cancer (1.23 MB)

Central Nervous System Tumours (1.22 MB)

Cervical Carcinoma (1.22 MB)

Cholangiocarcinoma (1.24 MB)

Colorectal Carcinoma (1.25 MB)

Ctdna Genetic Testing (1.27 MB)

EGFR Via Circulating DNA (1.23 MB)

Endometrial Carcinoma (1.13 MB)

GIST (0.16 MB)

Head & Neck Carcinoma (0.73 MB)

Lymphoma (1.14 MB)

Lung Carcinoma (1.16 MB)

Melanoma (1.24 MB)

NTRK Fusion (1.20 MB)

Ovarian Cancer (1.17 MB)

PD L1 28 8 For Nivolumab (1.22 MB)

Prostate Cancer (1.67 MB)

Sarcoma (1.25 MB)

Thyroid Carcinoma (1.24 MB)

Upper GI Carcinoma (1.24 MB)

Urothelial Carcinoma (1.24 MB)