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

ADH5 (CK5/14, CK7/18, p63)
Adipophilin
Adrenocorticotropic Hormone
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-6
Ber-EP4
Beta hCG
Beta-catenin
BK Virus (SV-40)
BNC5
c-Myc
C4d
CA IX
Cadherin-17
Calcitonin
Caldesmon
Calponin-1
Calretinin
CD1a
CD2
CD3
CD4
 CD5
CD7
CD8
CD10
CD15
CD31
CD34
CD38
CD43
CD44
CD45
CD45RO
CD57
CD61
CD74
CD138
CD163
CDX-2
CEA (monoclonal)
CEA (polyclonal)
Chromogranin A
CK5
CK5/6
CK7
CK10
CK14
CK17
CK20
CK903
CKAE1/AE3
CMV
Collagen Type IV
D2-40
 DAXX
DOG1
EMA
ERG
Factor VIII (von Willebrand Factor)
Factor XIIIa
FLI-1
Follicle Stimulating Hormone
Galectin-3
GCDFP-15
Glucagon
Glypican-3
Growth Hormone
H3K27me3
H. pylori
HBME-1
Hep Par 1
Her-2/neu
HHV-8
HMB-45
HNF-1beta
HSV I
HSV II
Human Placental Lactogen
IgD
IgG
IgG
IgG4
IgM
IMP3 (KOC)
Kappa Light Chains
Kidney-specific Cadherin
LEF-1
 L1-CAM
Luteinizing Hormone
Lysozyme
Mammaglobin
MART-1
Maspin
MCPyV
Microphthalmia Transcription Factor (MiTF)
MOC-31
MSI Panel (MLH1, MSH2, MSH6, PMS2)
MUC1
MUC5AC
Muscle-specific Actin (MSA)
Myeloperoxidase (MPO)
Myogenin
Myoglobin
NANOG
Napsin A (monoclonal)
Neurofilament
Neuron-specific Enolase (NSE)
Neuronal Nuclear Antigen (NeuN)
NKX2.2
NKX3.1
OCT4
p40
p57
p63
Pan-CK (MNF116)
Parathyroid Hormone
PAX2
PAX5
PAX6
PD-1
 Phosphohistone (PHH3)
PIN4 (CK903, p63, P504S)
Placental Alkaline Phosphatase
PLZF
PRAME
Progesterone Receptor (PR)
Prolactin
Prostate-specific Antigen
RCC Marker
S100
S100A6
S100P
SALL4
SATB2
Serotonin
Smooth Muscle Actin (SMA)
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 high risk 18 (RNA ISH) ROS1 (FISH) BRAF
ALBUMIN (RNA ISH) HPV low risk 6 (RNA ISH) Ploidy Analysis (FISH) EGFR
ALK (FISH) HPV- low risk (CISH) Synovial Sarcoma (FISH) KRAS
EBV (EBER) (CISH) Kappa Light Chains (CISH)   NRAS
ESWR1 (FISH) Lambda Light Chains (CISH) Other FISH for Solid Tumors (available upon request)  
HER2 Breast (FISH) MDM2 (FISH)    
HER2 Gastric (FISH) Napsin A (RNA ISH) 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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