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) CD43 HHV-8 p16
Adipophilin CD44 HMB-45 p40
Adrenocorticotropic Hormone CD45 HNF-1beta p57
ALBUMIN CD45RO HPV LR6 p63
ALK-1 CD5 HR HPV RNA Pan-CK (MNF116)
ALK-1 CD5 HSV I Parafibromin
Alpha-1-antitrypsin CD56 HSV II Parathyroid Hormone
Alpha-fetoprotein CD57 Human Placental Lactogen PAX2
AMACR (P504S) CD61 IDH1 PAX5
Amyloid A CD68 IgD PAX6
Androgen Receptor CD7 IgG PAX8
Arginase-1 CD79a IgG4 PD-1
ATRX CD8 IgM PDL1 SP142
B72.3 (TAG 72) CD99 IMP3 (KOC) Phosphohistone (PHH3)
BAP1 CDK4 Inhibin alpha PIN4 (CK903, p63, P504S)
Bcl-1 (Cyclin D1) CDX-2 INI-1 Placental Alkaline Phosphatase
Bcl-10 CEA (monoclonal) INSM1 PLZF
Bcl-2 CEA (polyclonal) Kappa Light Chains PMS2
Bcl-6 Chromogranin A Ki-67 (MIB-1) PRAME
Ber-EP4 CK14 L1-CAM Progesterone Receptor (PR)
Beta F1 CK17 LANGERIN Prolactin
Beta hCG CK18 LEF-1 Prostate-specific Acid Phosphatase
Beta-catenin CK19 LFABP QI-ER
BK Virus (SV-40) CK20 LMO2 RCC Marker
BNC5 CK5 Luteinizing Hormone S100
BOB.1 CK5/6 Lysozyme S100 red
Brachyury CK7 Mammaglobin S100A6
BRAF CK903 MART-1 S100P
c-Myc CKAE1/AE3 Maspin SALL4
C4d Claudin 1 MCPyV SATB2
CA IX CMV MGMT Ab-1 SDHB
Cadherin-17 Collagen Type IV Microphthalmia Transcription Factor (MiTF) SF-1
Calcitonin CRP MLH1 SMARCA2
Caldesmon D2-40 MOC-31 SMARCA4
Calponin-1 DAXX MSH2 SMH
Calretinin DDIT3 MSH6 Smooth Muscle Actin (SMA)
CAM 5.2 Desmin MSI Panel (MLH1, MSH2, MSH6, PMS2) SOX10
Cathepsin K DOG1 MUC1 SOX11
CD10 EMA MUC2 SOX17
CD105 ERG MUC5AC SOX2
CD117 Estrogen Receptor (ER) MUC6 Spirochete (T. pallidum)
CD123 Factor VIII (von Willebrand Factor) MUM1 SSTR2
CD138 Factor XIIIa Muscle-specific Actin (MSA) STAT6
CD15 FLI-1 MYB Synaptophysin
CD163 Follicle Stimulating Hormone Myeloperoxidase (MPO) TCR beta F1
CD19 Galectin-3 Myogenin TdT
CD1a GATA3 Myoglobin Thrombomodulin
CD2 GCDFP-15 Napsin A (monoclonal) Thyroglobulin
CD20 GFAP NAPSIN RNASCOPE Thyroglobulin
CD21 GLUT1 Neurofilament TIA-1
CD23 Glutamine synthetase Neuron-specific Enolase (NSE) TLE1
CD25 Glypican-3 Neuronal Nuclear Antigen (NeuN) Transcription Factor E3 (TFE3)
CD3 Growth Hormone NKX2.2 TROP2
CD30 H. pylori NKX3.1 TSH
CD31 H3.3G34W NUT Uroplakin II
CD34 H3K27me3 OCT4 Varicella Zoster Virus
CD35 HBME-1 Oligodendrocyte Transcription Factor 2 Villin
CD38 Hep Par 1 OTP Vimentin
CD4 Her-2/neu 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.