Clinic Name: Camilla T. Allen, MD Scott Chatterley, MD 3614 Meridian Street, Suite 100 Ryan R. Fortna, MD, PhD Clinic Address: Bellingham, WA 98225 Michael T. Kelly, MD, PhD Phone: (360) 734-2800 Fax: (360) 734-3818 Kelly A. Lloyd, MD Phone/Fax: Alfonso V. Masangkay, MD / John W. Hoyt, MD, Medical Director Greg M. Wolgamot, MD, PhD Physician Name: Copy to: Requested BY Requested

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ICD-9 Diagnosis Code(s): (REQUIRED) Specimen Source Information

Specimen Source: (check all that apply)  Cervical  Endocervical  Vaginal  Other Date & Time Collected: LMP: Reason for Visit:  Annual exam  Follow upREQUIRED exam  ABN bleeding  ABN discharge  STD Exposure  Depo  IUD  BCP  Hormones  Chemotherapy  Radiation  DES Prior Abnormal Pap: Date ______Prior Biopsy: Date ______

Menstrual Status:  Cyclic  Irregular  Amenorrhea  Pregnant  Post partum  Hysterectomy  Post meno  Hormone therapy PAP and HPV Tests (ThinPrep) Genital Organisms by PCR (ThinPrep or Swab)

 Pap test + HPV tests if indicated by ASCCP guidelines Individual organisms can be selected by circling each desired organism  Chlamydia & Gonorrhea (C. trachomatis & N. gonorrhoeae)  Pap test + high-risk HPV if ASCUS/AGC  Herpes panel (HSV 1 & HSV 2)  Pap test + high-risk HPV if ASCUS/AGC or higher  Trichomonas vaginalis  Pap test + high-risk HPV regardless of Pap diagnosis  Candida Vaginitis panel (C. albicans & C. glabrata)  Pap test only  Bacterial Vaginosis panel (Gardnerella, Atopobium, Megasphaera types 1 & 2, BVAB2, and Lactobacillus profiling*) *requires full panel HPV Primary Screening (ThinPrep* or Swab)  Aerobic Vaginitis panel (GBS, S. aureus, E. coli, & E. faecalis)  HPV Primary Screen*  Mycoplasma panel (M. genitalium & M. hominis)  Includes HPV 16/18 and non-16/18 high-risk HPV subtyping  Ureaplasma urealyticum  If submitted as ThinPrep*, will be reflexed to cytology if positive for non-16/18  Group B Streptococcus (GBS)  Reflex antibiotic resistance high-risk HPV  *Allergy to Penicillin* for GBS by PCR (if positive) ® * Cobas HPV Test on ThinPrep is FDA-approved as primary cervical cancer *Visit nwpathology.com for full list of available organisms. screening for women 25 years of age and older Surgical Pathology Oral Organisms by PCR (Swab or ThinPrep) Individual organisms can be selected by circling each desired organism Date & Time Collected: ______Specimen Source(s)  High-risk HPV (HPV 16 and HPV 18)  Low-risk HPV (HPV 6/11)  Herpes Panel (HSV 1 & HSV 2) 1. ______3. ______ Chlamydia & Gonorrhea (C. trachomatis & N. gonorrhoeae)  Candida panel (C. albicans & C. glabrata)  Other* ______ Oral Cytology 2. ______4. ______*Visit nwpathology.com for full list of available organisms. (ThinPrep)

Additional Clinical Information/Previous History