Mass Histology Service, Inc.
SERVICE REQUEST FORM
(print out and then complete, check or circle appropriate answers)

Service requested: Routine Priority RUSH
Return delivery by: UPS FedEx U.S. Mail No Preference
Your company’s UPS or FedEx account number (optional): __________________________
Would you like insurance on your returned items? NO YES AMT: $__________
Return postage speed: Ground 2-day Overnight

Date:________________________________
Company:____________________________
Phone #:_____________________________     Ext. ______________________________
P.I.: ________________________________  email: ______________________________
Exp. ID #:_________________________________________________________________
# specimens: _____________  Type of specimens: ________________________________
Fixative: _________________ PLEASE SHIP IN 70% ALCOHOL

Submitted as: free-floating in cassettes paraffin blocks  frozen other

Services requested: PLEASE INCLUDE A SPECIMEN MANIFEST & YOUR RETURN ADDRESS!
     √                              
_____ Decalcify
_____ Process and embed
_____ Cut and stain (first H&E)
_____ Cut and stain (how many?) _______ additional H&Es same level deeper levels
_____ Cut (how many?) __________ Unstained slides per specimen
_____ Special stains: __________________________________________________
_____ Immunos: __________________________________________________
_____ Other: __________________________________________________

Do you want your unstained frozen sections fixed in acetone? YES NO

Instructions and comments: __________________________________________________
_________________________________________________________________________

Photographs to be taken: YES NO (gross microscopic)
Pathology report? YES NO (descriptive check-off)
Blocks returned? YES NO

_________________________________________________________________________

Method of payment:

Purchase order #: _______________________

Charge card:     MasterCard        Visa _____ security # on back of card (3 numbers)

Card number:   ___________________________   expiration:  month: _____  year: _____

Name on card:  _________________________ Zip Code where credit card bill is sent to: ________

PLEASE READ ALL INSTRUCTIONS AND DISCLAIMERS ON “PRICING” AND “SENDING” PAGES