Geisinger IHC

Geisinger Medical Laboratories
100 North Academy Avenue
Danville, PA 17822-1920
Attention: Pathology Secretary
Myra Wilkerson, MD, Medical Director

1-800-695-6491

IMMUNOHISTOCHEMISTRY AND IN SITU HYBRIDIZATION REQUEST FORM

*ORDERING FACILITY / PROVIDER INFORMATION
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
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

ADH5 (CK5/14, CK7/18, p63)
Adipophilin
Adrenocorticotropic Hormone
ALK-1
Alpha-1-antichymotrypsin
Alpha-1-antitrypsin
Alpha-fetoprotein
AMACR (P504S)
Amyloid A
Amyloid Transthyretin
Androgen Receptor
Annexin A1
ATRX
B72.3 (TAG 72)
BAP1
Bcl-1 (Cyclin D1)
Bcl-2
Bcl-6
Ber-EP4
Beta hCG
Beta-catenin
BK Virus (SV-40)
BNC5
BOB.1
BRAF
c-Myc
C4d
CA IX
Cadherin-17
Calcitonin
Caldesmon
Calponin-1
CAM 5.2
CD1a
CD2
CD3
CD4
CD5
CD7
CD8
CD10
CD15
 CD20
CD21
CD23
CD30
CD31
CD34
CD35
CD38
CD43
CD44
CD45
CD45RO
CD56
CD57
CD61
CD68
CD74
CD99
CD105
CD117
CD138
CD163
CDK4
CDX-2
CEA (monoclonal)
CEA (polyclonal)
Chromogranin A
CK5
CK5/6
CK7
CK10
CK14
CK17
CK19
CK20
CK903
CKAE1/AE3
CMV
Collagen Type IV
D2-40
DAXX
Desmin
 DOG1
E-cadherin
Elastin
EMA
ERG
Estrogen Receptor (ER)
Factor VIII (von Willebrand Factor)
Factor XIIIa
FLI-1
Follicle Stimulating Hormone
Galectin-3
GATA3
GCDFP-15
GFAP
Glucagon
GLUT1
Glypican-3
Granzyme B
Growth Hormone
H3K27me3
HBME-1
Hep Par 1
Her-2/neu
HHV-8
HMB-45
HNF-1beta
HSV I
HSV II
Human Placental Lactogen
IDH1
IgD
IgG
IgG4
IgM
Inhibin alpha
INI-1
Insulin
Kappa Light Chains
Ki-67 (MIB-1)
Ki67/Mart-1
Kidney-specific Cadherin
Luteinizing Hormone
 Lysozyme
Mammaglobin
MART-1
Maspin
Maspin/VHL
MCPyV
Microphthalmia Transcription Factor (MiTF)
MLH1
MOC-31
MSH2
MSH6
MSI Panel (MLH1, MSH2, MSH6, PMS2)
MUC1
MUC4
MUC5AC
MUC6
MUM1
Muscle-specific Actin (MSA)
Myeloperoxidase (MPO)
MyoD1
Myogenin
Myoglobin
NANOG
Napsin A (monoclonal)
Neurofilament
Neuron-specific Enolase (NSE)
Neuronal Nuclear Antigen (NeuN)
NKX2.2
NKX3.1
OCT4
p16
p40
p53
p57
p63
p120 Catenin
Pan-CK (MNF116)
Parathyroid Hormone
PAX2
PAX5
PAX8
Phosphohistone (PHH3)
 PIN4 (CK903, p63, P504S)
Placental Alkaline Phosphatase
PLZF
PMS2
Procollagen Type 1
Progesterone Receptor (PR)
Prolactin
Prostate-specific Antigen
RCC Marker
S100
S100A1
S100A6
SALL4
SATB2
Serotonin
Smooth Muscle Actin (SMA)
Smooth Muscle Myosin, Heavy Chain
Somatostatin
SOX2
SOX10
SOX11
Spirochete (T. pallidum)
Synaptophysin
TdT
Thrombomodulin
Thyroglobulin
Thyroid Transcription Factor 1 (TTF1)
Transcription Factor E3 (TFE3)
Trefoil Factor 1 (TFF1)
Trefoil Factor 3 (TFF3)
TROP2
Tryptase
TSH
Uroplakin II
Varicella Zoster Virus
Villin
Vimentin
von Hippel-Lindau (VHL)

Other:

IN SITU HYBRIDIZATION STUDIES - FISH and CISH
PCR STUDIES
ALK (FISH) HPV High Risk 16,18 CISH Other FISH for Solid Tumors
      (available upon request)		 BRAF
EBV (EBER) CISH Kappa Light Chains CISH Ploidy Analysis (FISH) EGFR
HER2 Breast (FISH) Lambda Light Chains CISH Synovial Sarcoma (FISH) KRAS
HER2 Gastric (FISH) MDM2 (FISH) UroVysion (33 mL random urine)  

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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