Routing Form for Eye Pathology

A variety of routing forms are supplied for your convenience. Instructions for processing, demographic information, clinical history and your personal notes about each case should be kept on the routing forms.

Name:________________ ROUTING FORM Accession Date:___________
Date / Pending Hospital #: _______________Notes: _____________________
_____________________
_____________________

Specimen Container label for:
#1 ________________________ #2 _____________________ #3 _________________:





x x mm x x mm x x mm

Ink color ______ Ink color ______ Ink color ______

Cassette _____ Cassette _____ Cassette _____
Embedding Instructions: block(s)______( ) On Edge ( ) Flat Face ( ) As Shown

Sectioning Instructions: Face block; Take ribbons/ sections at the following intervals
( )1 stained, 1 unstained block(s)______
( ) Deeper q 30th section x ____ or (through block) block(s)______
( ) Deeper q 50 x ____ or (through block) block(s)______
( ) Deeper every 20th section x ____ (through block)
( ) Cornea –face, 1 section stained / 1unstained / 1 PAS
( ) Pterygium – 1 H&E – deeper q50x5 stained w/PAS
( ) ____________ unstained slides


( ) Routine Infectious Package Gram (+/-) Brown-Hopps GMST, PAS, AFB,
( ) Corneal Dystrophy Package Alcian Blue pH 0.4; PAS; Congo Red; Masson's Trichrome

( ) PAS all corneas and eyes
( )Jones
( )GMST
( ) Verhoff Van Gieson
( ) Oil Red O
( )AFB
( )Silver
( )Steiner-Steiner
( ) Gram Stain
( )Giemsa
( )Fite's Stain
( )Warthin-Starry
( )Alcian Blue pH 0.4
( )Von Kossa
( ) Masson's Trichrome
( )Congo Red
( )Crystal Violet
( ) Thioflavin T
( )Prussian Blue
( )Gordon-Sweet
( ) Heidenhain Hematoxylin
( )PTAH
( )Sudan Black
( ) Mucicarmine