Histopathology Form v 0.01

AMRS ID Number:

Given Name:

Family Name:

Middle Name:

Gender:

Date Of Birth:

Name of Dispensary:*

Encounter Date:*

Body Part Where Specimen Was Collected? *

How was specimen collected?*

Provide Location Of Specimen

Provide location where biopsy for specimen was done: __O'clock

Pathological Diagnosis for Cervical Specimen

Pathological Diagnosis for Vaginal Specimen

Pathological Diagnosis for Vulval Specimen

Provider Name:

Provider's system-id:*

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