Geisinger IHC

Geisinger Medical Laboratories
100 North Academy Avenue
Danville, PA 17822-1920
Attention: Pathology Secretaries
1-800-695-6491

IMMUNOHISTOCHEMISTRY AND IN SITU HYBRIDIZATION REQUEST FORM


*ORDERING FACILITY / PROVIDER INFORMATION
AT THIS TIME WE CAN ONLY ACCEPT SPECIMENS FROM FACILITIES & PROVIDERS IN THE US
PATIENT INFORMATION
ORDERING FACILITY
*Blocks will be returned and INVOICE SUBMITTED to ordering facility. 		PATIENT NAME (FIRST, LAST, MIDDLE INITIAL)
ADDRESS
MRN DATE OF BIRTH SEX
(MM/DD/YYYY)
CITY STATE ZIP
CLINICAL HISTORY
*Please send preliminary or final report for full consultations
PHONE FAX
ORDERING PROVIDER NPI
SEND ADDITIONAL COPY OF REPORT TO
BILLING INFORMATION
BILLING CONTACT NAME
BILLING CONTACT E-MAIL ADDRESS
SPECIMEN INFORMATION
WHEN COLLECTED: DATE TIME
BREAST RECEPTOR STUDIES
ISCHEMIC TIME   DATE TIME
IN FORMALIN      DATE TIME
CASE ACCESSION # BLOCK # TISSUE SOURCE
PLEASE SUBMIT A SEPARATE FORM FOR EACH BLOCK
PERSON COMPLETING FORM
PHONE DATE
INSTRUCTIONS (Please select one option below and the corresponding stains as appropriate)
PERFORM STAINS REQUESTED (NO
     INTERPRETATION  (CHECK STAINS BELOW)
OR
 IMMUNOHISTOCHEMISTRY CONSULT WITH
     DIAGNOSIS. APPROPRIATE STAINS WILL BE
      SELECTED BY OUR PATHOLOGISTS
PERFORM AND INTERPRET STAINS REQUESTED
      (CHECK STAINS BELOW)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
IMMUNOHISTOCHEMISTRY
ADH5 (CK5/14, CK7/18, p63) CD44 Her-2/neu p16
Adipophilin CD45 HHV-8 p40
Adrenocorticotropic Hormone CD45RO HMB-45 p57
ALBUMIN CD5 HNF-1beta p63
ALK-1 CD5 HPV LR6 Pan-CK (MNF116)
ALK-1 CD56 HR HPV RNA Parafibromin
Alpha-1-antitrypsin CD57 HSV I Parathyroid Hormone
Alpha-fetoprotein CD61 HSV II PAX2
AMACR (P504S) CD68 Human Placental Lactogen PAX5
Amyloid A CD7 IDH1 PAX6
Androgen Receptor CD79a IgD PAX8
Arginase-1 CD8 IgG PD-1
ATRX CD99 IgG4 PDL1 SP142
B72.3 (TAG 72) CDK4 IgM Phosphohistone (PHH3)
BAP1 CDX-2 IMP3 (KOC) PIN4 (CK903, p63, P504S)
Bcl-1 (Cyclin D1) CEA (monoclonal) Inhibin alpha Placental Alkaline Phosphatase
Bcl-10 CEA (polyclonal) INI-1 PLZF
Bcl-2 Chromogranin A INSM1 PMS2
Bcl-6 CK14 Kappa Light Chains PRAME
Ber-EP4 CK17 Ki-67 (MIB-1) Progesterone Receptor (PR)
Beta F1 CK18 L1-CAM Prolactin
Beta hCG CK19 LANGERIN Prostate-specific Acid Phosphatase
Beta-catenin CK20 LEF-1 QI-ER
BK Virus (SV-40) CK5 LFABP RCC Marker
BNC5 CK5/6 LMO2 S100
BOB.1 CK7 Luteinizing Hormone S100 red
Brachyury CK903 Lysozyme S100A6
BRAF CKAE1/AE3 Mammaglobin S100P
c-Myc Claudin 1 MART-1 SALL4
C4d CMV Maspin SATB2
CA IX Collagen Type IV MCPyV SDHB
Cadherin-17 CRP MGMT Ab-1 SF-1
Calcitonin D2-40 Microphthalmia Transcription Factor (MiTF) SMARCA2
Caldesmon DAXX MLH1 SMARCA4
Calponin-1 DDIT3 MOC-31 SMH
Calretinin Desmin MSH2 Smooth Muscle Actin (SMA)
CAM 5.2 DOG1 MSH6 SOX10
Cathepsin K E-cadherin MSI Panel (MLH1, MSH2, MSH6, PMS2) SOX11
CD10 Elastin MUC1 SOX17
CD105 EMA MUC2 SOX2
CD117 ERG MUC5AC Spirochete (T. pallidum)
CD123 Estrogen Receptor (ER) MUC6 SSTR2
CD138 Factor VIII (von Willebrand Factor) MUM1 STAT6
CD15 Factor XIIIa Muscle-specific Actin (MSA) Synaptophysin
CD163 FLI-1 MYB T-Pit
CD19 Follicle Stimulating Hormone Myeloperoxidase (MPO) TCR beta F1
CD1a Galectin-3 Myogenin TdT
CD2 GATA3 Myoglobin Thrombomodulin
CD20 GCDFP-15 Napsin A (monoclonal) Thyroglobulin
CD21 GFAP NAPSIN RNASCOPE Thyroglobulin
CD23 GLUT1 Neurofilament TIA-1
CD25 Glutamine synthetase Neuron-specific Enolase (NSE) TLE1
CD3 Glypican-3 Neuronal Nuclear Antigen (NeuN) Transcription Factor E3 (TFE3)
CD30 Growth Hormone NKX2.2 TROP2
CD31 H. pylori NKX3.1 TSH
CD34 H3.3G34W NUT Uroplakin II
CD35 H3K27me3 OCT4 Varicella Zoster Virus
CD38 HBME-1 Oligodendrocyte Transcription Factor 2 Villin
CD4 Hepatitis B Virus Core Antigen OTP Vimentin
CD43 Hepatitis B Virus Surface Antigen p120 Catenin WT1

Other:

IN SITU HYBRIDIZATION STUDIES
1p19qDEL (FISH) HER2 Breast (FISH) HPV low risk 6 (RNA ISH) MDM2 (FISH)
ALBUMIN (RNA ISH) HER2 Gastric (FISH) Kappa Light Chains (CISH) Napsin A (RNA ISH)
EBV (EBER) (CISH) HPV high risk 18 (RNA ISH) Lambda Light Chains (CISH) Ploidy Analysis (FISH)

This will generate a PDF of your order for you to print and submit with your block or other specimen. 

Fields labeled in red are MANDATORY.