I attest that the above listed next of kin has authorized,                        , (reviewing pathologist) to examine formalin-fixed tissue and/or microscopic slides from the above decedent that are in the possession of the Delaware County Office of the Medical Examiner (DCOME), and, if necessary, to submit said tissue for processing into microscopic slides.

I also acknowledge that:

1) The reviewing pathologist will be responsible for submitting any formalin-fixed tissue for thepreparation of microscopic slides. This submission will occur at the DCOME, in the presence of DCOME personnel, and I (or the designated pathologist) will be responsible for scheduling any visit(s) to the DCOME for this purpose. Once submitted, preparation of slides will be performed by the DCOME's contracted histology laboratory. The cost of a DCOME Pathologist to be present is $220.00 which includes one H&E slide.

2)Unauthorized removal of any formalin-fixed tissue from the DCOME by the reviewing pathologist is prohibited. Any histology tissue blocks created by submission of tissue by the reviewing pathologist will remain in the possession of the DCOME.

3) I or my law firm will be financially responsible for the cost of microscopic slide preparation, and I understand that slides will not be released until online payment is received by the DCOME (payment page: https://delco.jotform.com/221103706558047).  The costs are as follows: $20.00 per H&E slide if the tissue is submitted by the reviewing pathologist, or $16.00 per H&E slide if prepared from existing tissue blocks. Additional fees will apply if special and/or immunohistochemical stains are ordered. If slides are requested please provide a preferred contact and shipping address.

4)The DCOME will not be held liable for any personal injury or losses sustained by non-DCOME personnel during visits to our facility, including responsibility for reimbursement of medical expenses and compensation for damage to personal property resulting from their activities at the DCOME. This includes injuries/losses resulting from negligent actions or omissions by the visitor(s), negligent actions or omissions of others, or the condition of the facility.