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) CD4 HMB-45 p40
Adipophilin CD43 HNF-1beta p57
Adrenocorticotropic Hormone CD44 HPV LR6 p63
ALBUMIN CD45 HR HPV RNA Pan-CK (MNF116)
ALK-1 CD45RO HSV I Parafibromin
ALK-1 CD5 HSV II Parathyroid Hormone
Alpha-1-antitrypsin CD5 Human Placental Lactogen PAX2
Alpha-fetoprotein CD56 IDH1 PAX5
AMACR (P504S) CD57 IgD PAX6
Amyloid A CD61 IgG PAX8
Androgen Receptor CD68 IgG4 PD-1
Arginase-1 CD7 IgM PDL1 SP142
ATRX CD79a IMP3 (KOC) Phosphohistone (PHH3)
B72.3 (TAG 72) CD8 Inhibin alpha PIN4 (CK903, p63, P504S)
BAP1 CD99 INI-1 Placental Alkaline Phosphatase
Bcl-1 (Cyclin D1) CDK4 INSM1 PLZF
Bcl-10 CDX-2 Kappa Light Chains PMS2
Bcl-2 CEA (monoclonal) Ki-67 (MIB-1) PRAME
Bcl-6 CEA (polyclonal) L1-CAM Progesterone Receptor (PR)
Ber-EP4 Chromogranin A LANGERIN Prolactin
Beta F1 CK14 LEF-1 Prostate-specific Acid Phosphatase
Beta hCG CK17 LMO2 QI-ER
Beta-catenin CK18 Luteinizing Hormone RCC Marker
BK Virus (SV-40) CK19 Lysozyme S100
BNC5 CK20 Mammaglobin S100 red
BOB.1 CK5 MART-1 S100A6
Brachyury CK5/6 Maspin S100P
BRAF CK7 MCPyV SALL4
c-Myc CK903 MGMT Ab-1 SATB2
C4d CKAE1/AE3 Microphthalmia Transcription Factor (MiTF) SDHB
CA IX Claudin 1 MLH1 SF-1
Cadherin-17 CMV MOC-31 SMARCA2
Calcitonin Collagen Type IV MSH2 SMARCA4
Caldesmon CRP MSH6 SMH
Calponin-1 D2-40 MSI Panel (MLH1, MSH2, MSH6, PMS2) Smooth Muscle Actin (SMA)
Calretinin DAXX MUC1 SOX10
CAM 5.2 Desmin MUC2 SOX11
Cathepsin K DOG1 MUC5AC SOX17
CD10 EMA MUC6 SOX2
CD105 ERG MUM1 Spirochete (T. pallidum)
CD117 Estrogen Receptor (ER) Muscle-specific Actin (MSA) SSTR2
CD123 Factor VIII (von Willebrand Factor) MYB STAT6
CD138 Factor XIIIa Myeloperoxidase (MPO) Synaptophysin
CD15 FLI-1 Myogenin TCR beta F1
CD163 Follicle Stimulating Hormone Myoglobin TdT
CD19 Galectin-3 Napsin A (monoclonal) Thrombomodulin
CD1a GCDFP-15 NAPSIN RNASCOPE Thyroglobulin
CD2 GFAP Neurofilament Thyroglobulin
CD20 GLUT1 Neuron-specific Enolase (NSE) TIA-1
CD21 Glutamine synthetase Neuronal Nuclear Antigen (NeuN) TLE1
CD23 Glypican-3 NKX2.2 Transcription Factor E3 (TFE3)
CD25 Growth Hormone NKX3.1 TROP2
CD3 H. pylori NUT TSH
CD30 H3.3G34W OCT4 Uroplakin II
CD31 HBME-1 Oligodendrocyte Transcription Factor 2 Varicella Zoster Virus
CD34 Hep Par 1 OTP Villin
CD35 Her-2/neu p120 Catenin Vimentin
CD38 HHV-8 p16 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.