Skin Smear / Biopsy Chart
Date: Patient’s Name (Last, First, Middle): HD ID No: Date of Birth: Social Security Number: Phone results to:
Skin Smear Sites (1)- (2)- (3)- (4)- (5)- (6)-
Biopsy Sites (1)- (2)- (3)- (4)- (5)- (6)-
Private Physician: Name: Address:
