DAHL-CHASE DIAGNOSTIC SERVICES

417 STATE STREET

WEBBER WEST, SUITE 540
BANGOR, ME 04401

SPECIMEN RELEASE FORM

PATIENT NAME & DATE: ____________________________________

RE: Return of ______________________________________________

‰ Patient will pick up

‰ Funeral Home will pick up (Funeral Home: _______________________)

Dahl-Chase Diagnostic Services will hold the specimen up to 30 days after the report is
finalized. After that time, the specimen will be discarded per the appropriate protocol.

This paper acknowledges receipt of specimen _________________________, which I

have indicated to the Pathology Department that I would like to have for personal
purposes.

I understand that surgical specimens are the property of Dahl-Chase Diagnostic

Services and that Pathology has released this tissue specimen to me at their discretion.
By signing this paper I understand that I undertake all responsibility in the handling of
this tissue. Dahl-Chase Diagnostic Services cannot be held liable for any reason once
the tissue specimen is under my control.

I understand that the specimen may have been in 10% formalin which has the following
caution:
FORMALDEHYDE: Toxic by inhalation and if swallowed. Irritating the eyes, respiratory
system, and skin. May cause sensitization by inhalation or skin contact. Risk of serious
damage to the eyes. May cause cancer. Repeated or prolonged exposure increases
the risk.

I further understand that the specimen is a biohazard specimen (may create a risk for
exposure to HIV infection, hepatitis, and/or tuberculosis).

I, ________________________________________________________, the patient

requesting the specimen, have read and understand the above.

PATIENT SIGNATURE: ___________________________________DATE: __________

WITNESS: _____________________________________________ DATE: __________

Please return to Dahl-Chase Diagnostic Services/Pathology, 417 State Street, Webber

West, Ste. 540 Bangor, Maine 04401.

Signature upon receipt of specimen: _________________________ DATE:__________

Please return form to Dahl-Chase within 2 weeks of receipt.