IMMUNOHISTOCHEMISTRY AND SPECIAL STAIN REQUEST FORM Practice name: Ordering physician name: Date: Block: Collection Date:

Patient name: Date of birth: Gender: Specimen Site:

IMMUNOHISTOCHEMISTRY CHECK ONE:  GLOBAL, TECHNICAL WITH INTERPRETATION (SLIDES NOT RETURNED) TECHNICAL ONLY (SLIDES RETURNED) 88342: GLOBAL ONLY BRAF V600E Calponin Cytokeratin 5/6 Hepatitis B core antigen/HBCAG cMET Calretinin Cytokeratin 7 Hepatitis B surface antigen/HBSAG ER Caspase-3 Cytokeratin AE1/AE3 HepPar 1/Anti-human hepatocyte PR CD10 (calla) Cytokeratin CAM 5.2 Herpes virus I and II HER2 CD123 Cytokeratin MAK-6 Herpes virus type 8, latent nuclear Ag IDH1, mutant CD138 (syndecan) Cytomegalovirus/CMV HMB45 (melanoma) MMR panel (MLH1, MSH2, MSM6 and PMS2) CD1A D2-40 lymphatic marker Human chorionic gonadotropin/HCG CD20 Desmin IgA 88342 CD3 DOG-1 protein IgG Adenovirus CD31 DYSFERLYN IgG4A Adrenocorticotropic hormone (ACTH) CD34 (endothelium) Dystrophin 1 IMP3 (KOC) Alk-1 protein CD34 (stem cell) Dystrophin 2 Inhibin Alpha 1 antichymotrypsin/A1ACT CD4 (t-cell helper/inductor) Dystrophin 3 Insulin Alpha 1 antitrypsin/A1AT CD43 E-Cadherin JC virus Alpha 1 fetoprotein/AFP CD44 CD45 Epithelial membrane Ag Kappa Alpha-synuclein (LCA) Epstein-Barr virus LMP KI-67, nuclear antigen, MIB1 Amyloid A component CD45RO (UCHL1) (t-cell) ERG KP1-macrophage, CD68 Amyloid precursor protein CD5 (t-cell) Ewing’s sarcoma/CD99 Lambda Androgen receptor CD56 (NCAM) Factor 13a LC3B Annexin A10 CD61 Factor VIII LEU-7 myelin-associated glycoprotein (CD57) Anti-thyroid transcription factor-1 (TTF-1) CD68 (macrophage, KP1) Follicle stimulating hormone Leu-M-1 (CD15) ATRX CD7 (t-cell) Galectin–3 Luteinizing hormone B-amyloid CD71 (erythroid) Gastrin Lysozyme (muramidase) B72.3 (tumor-associated glycoproteins) CD79a (b-cell) GATA-3 Mammaglobin Baf47 (INI-1) CD8 - suppressor/cytotoxic GCDFP MDM2 protein BCL 2 oncoprotein CDX2 Glial fibrillar acid protein (GFAP) Melan-A BCL6 protein CEA - mono Glucagon Melanoma associated antigen Ber-EP4 CEA - poly Glucose transporter 1 Microphthalmia transcription factor (MITF) Beta catenin Chromogranin Glutamine synthetase MUC4 BK virus Chymotrypsin Glycophorin A MUM-1 protein Brachyury (notochord) Collagen IV Glypican-3 Muscle actin, HHF35 C-KIT/CD117 Cyclin-D1 Growth hormone (GH) Myeloperoxidase C4d complement (C4d) Cytokeratin 19 HBMEI - mesothelial cell Myogenin CA-125 Cytokeratin 20 Helicobacter pylori antibody Myoglobin Calcitonin Cytokeratin 34BE12-HMW Hemoglobin Myosin 2 Caldesmon

University of Florida Health Pathology Laboratories | 4800 SW 35th Drive | Gainesville, FL 32608 MORE  Toll-free: 888.375.LABS (5227) | Fax: 877.640.6465 | pathlabs.ufl.edu Revised 12/8/17

88342 (continued) 88312 (continued) 88313 (continued)

Myosin 2/1 Somatostatin Acid fast - nocardia Prussian blue - hemosiderin (Fe) NAPSIN-A SOX10 Acid fast – TB Reticulin (Gordon and Sweet’s method) Neurofilament (non-p) NF-NP SOX11 GIEMSA - DIF Quik Trichome - Gomori (muscle Bx) Neurofilament/NF Spectrin 1 GMS fungus Trichrome – Masson blue Neuron Specific Enolase/NSE STAT6 GMS nocardia Von Kossa- calcium Neuronal nuclei antibody/NeuN Surfactant apoprotein A GMS pneumocystis OCT - 2 Surfactant protein B Gram stain OCT - 4 germ cell marker Synaptophysin Mucicarmine - cryptococcus DOUBLE-STAINS p16 (a cyclin-dependent kinase inhibitor) T-cell receptor beta (TCR beta F1) PAS - fungus p63/34BE12 p504S TAU protein Steiner - cat scratch p504S/ERG p53 protein Terminal deoxy transferase (TDT) Steiner - helicobacter p57 protein TFE3 Steiner - spirochetes TRIPLE-STAIN p63 protein Thyroglobulin 88313 p63/34BE12/p504S Pan-cytokeratin (AEI/3) Thyroid stimulating hormone (TSH) Parathyroid hormone Toxoplasma gondii (TOXO) Alcian blue pH 2.5 PANELS Parvovirus B19 Transthyretin Colloidal iron Kappa/Lambda IHC PAX5 gene product immunostain Trypsin Congo red-amyloid Kappa/Lambda ISH PAX-8 protein Tryptase (mast cell tryptase) Elastin Verhoeff Vangieson (VVG) p53/CK20/CD44 Perforin Tyrosinase Fontana Masson - argentaffin

PGP 9.5 (protein gene product) Ubiquitin Fontana Masson - melanin

Phosphohistone-H3 (PHH3) (mitotic) Uroplakin 3 Fontana Masson - melanin (bleach) Placental alkaline phosphatase (PLA Varicella Zoster virus (VZV) GMS urates * Prolactin Villin Lendrum - fibrin IMMUNOGLOBULIN G (IgG) STAINS Prostatic acid phosphatase (PSAP) Vimentin Lendrum- skeleton muscle IgG1 Prostatic specific antigen (PSA) Wilm's tumor protein (WT-1) Luxol fast blue - H&E (LFB-H&E) IgG2 Renal cell carcinoma antigen (RCC) 88365 (in-situ hybridization) Luxol fast blue - PAS (LFB-PAS) IgG3 S100 Mucicarmine - epithelial mucins IgG4 S100P EBER - Epstein-Barr early RNA ISH Oil red O, cytospins SALL4 Kappa in-situ hybridization (mRNA) PAS - basement membrane * If only one stain is ordered, 88350 is SATB2 Lambda in-situ hybridization (mRNA) Periodic acid meth silver stain (PAMS) billed; 88346 is also billed for each Sarcoglycan A Periodic acid Schiff stain (PAS) additional IgG stain performed. Sarcoglycan B SPECIAL STAINS Periodic acid Schiff (frozen sections) Sarcoglycan D 88312 Periodic acid Schiff (muscle Bx) Sarcoglycan G Periodic acid Schiff with dig Smooth muscle actin (SMA) Acid fast - leprosy, Fite, nocardia PTAH for fibrin Smooth muscle myosin heavy chain Acid fast - nocardia PTAH – gliosis Smoothelin Acid fast - leprosy, Fite, nocardia PTAH - skeletal muscle

University of Florida Health Pathology Laboratories | 4800 SW 35th Drive | Gainesville, FL 32608 MORE  Toll-free: 888.375.LABS (5227) | Fax: 877.640.6465 | pathlabs.ufl.edu Revised 12/8/17