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Get Cervical Histology Form - CervicalCheck - Cervicalcheck

D Day Month Year Day Month Year Consultation Date Hospital Chart No. Day Month Year Referral Reason Date of Birth Index / Referral Smear Surname Block capital letters to be used in filling out form Cytology LB ID Cytology Lab accession number First Name Middle Name Date of Smear Smear Result Surname at Birth Colposcopy Mother s Maiden Name Postal Address for Correspondence Impression Specimen site Priority Please tick 1. Contact Telephone No. 2. Mobile No. 3. I h.

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