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
CITY STATE ZIP
CLINICAL HISTORY
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
PARAFFIN BLOCK Tissue Block PERSON COMPLETING FORM
FIXATION Formalin PHONE DATE
INSTRUCTIONS
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

CK18
CD123
ADH5 (CK5/14, CK7/18, p63)
Adipophilin
Adrenocorticotropic Hormone
ALK-1
Alpha-1-antitrypsin
AMACR (P504S)
Amyloid A
Arginase-1
ATRX
B72.3 (TAG 72)
BAP1
Bcl-1 (Cyclin D1)
Bcl-2
Bcl-6
Ber-EP4
Beta-catenin
BK Virus (SV-40)
BNC5
BRAF
c-Myc
C4d
CA IX
Cadherin-17
Calcitonin
Caldesmon
Calponin-1
Calretinin
CAM 5.2
 CD1a
CD2
CD3
CD4
CD5
CD5
CD8
CD10
CD15
CD31
CD34
CD38
CD43
CD44
CD45
CD57
CD61
CD68
CD79a
CD163
CDK4
CDX-2
CEA (monoclonal)
CEA (polyclonal)
CK5
CK5/6
CK7
CK14
CK20
CK903
 CKAE1/AE3
CMV
Collagen Type IV
D2-40
DAXX
DOG1
EMA
ERG
Estrogen Receptor (ER)
Factor VIII (von Willebrand Factor)
Factor XIIIa
FLI-1
Follicle Stimulating Hormone
Galectin-3
Growth Hormone
H3K27me3
H. pylori
HBME-1
Hep Par 1
Her-2/neu
HHV-8
HMB-45
HNF-1beta
HSV I
HSV II
IgD
IgG4
IgM
IMP3 (KOC)
Kappa Light Chains
 LEF-1
L1-CAM
Luteinizing Hormone
Lysozyme
Mammaglobin
MART-1
Maspin
MCPyV
MOC-31
MSI Panel (MLH1, MSH2, MSH6, PMS2)
MUC1
Muscle-specific Actin (MSA)
Myeloperoxidase (MPO)
Myogenin
Myoglobin
Napsin A (monoclonal)
Neurofilament
Neuron-specific Enolase (NSE)
NKX2.2
NKX3.1
OCT4
p40
p57
p63
p120 Catenin
Pan-CK (MNF116)
Parathyroid Hormone
PAX5
PAX6
PD-1
 Phosphohistone (PHH3)
PIN4 (CK903, p63, P504S)
Placental Alkaline Phosphatase
PLZF
PRAME
Progesterone Receptor (PR)
Prolactin
RCC Marker
S100
S100A6
S100P
SALL4
SATB2
SMARCA2
SMARCA4
SMH
SOX2
SOX10
SOX11
Spirochete (T. pallidum)
TdT
Thrombomodulin
Thyroglobulin
TSH
Uroplakin II
Varicella Zoster Virus
Villin
Vimentin

Other:

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

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.

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