Dermatology Requisition

Patient Information

Physician Information

Collection Information

Billing Information (please attach copies of all cards, front and back)

(See List Below)

Specimen Submitted

Biopsy Site (Laterality)
Collection Method
Rule Out
Clinical Diagnostics
(See List Below)

Patient Consent: I authorize payment to be paid to A2Z Diagnostics, LLC shown above for laboratory testing benefits otherwise payable to me. I understand I am financially responsible to A2Z Diagnostics, LLC for charges not paid or payable under my insurance program attached. I understand that my insurance may not be able to honor this request. If they cannot, they will pay the benefits directly to me as the insured and will direct payment to A2Z Diagnostics, LLC.