Grand Rounds Submission Form

Please complete the form below to submit a patient to Grand Rounds. Fields marked with * are required.

Date of Grand Rounds *

Submitting physician *

Physician's preferred contact (email address or phone number)

Patient initials *

Reason for presentation * Reason for presentation

Request dermatopathology review? *

Originating pathology laboratory * Originating pathology laboratory

Accession number *

Originating pathology laboratory for additional pathology Originating pathology laboratory for additional pathology

Accession number for additional pathology

Permission to review pathology *

By checking this box, I permit the Washington University Dermatopathology Center to obtain and review pathology from this patient.

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Please note:

All submissions must be entered by 5 pm on the Tuesday before the requested Grand Rounds date.
Please do not include protected health information on this form. If you need to submit additional information about your patient for outside pathology review (eg pathology report or additional identifying information), please fax the information to the Washington University Dermatopathology Center staff at (314) 362-5701 or call (314) 362-5757; on the fax cover sheet, note that this is related to a Grand Rounds patient and include the date of Grand Rounds.
The Washington University Dermatopathology Center will coordinate obtaining slides for review prior to Grand Rounds. By submitting this form, you are providing permission for the Center to obtain and review pathology from the outside laboratory. All related costs will be borne by the Center, and no feel will be charged.
Please allow 1-2 weeks for the Washington University Dermatopathology Center to obtain your patient’s slides.