IMMUNOHISTOCHEMISTRY REQUEST FOR CONSULTATION

PATIENT NAME (LAST, FIRST, MIDDLE)

MEDICAL RECORD # BIRTHDATE AGE SEX

ACCESSION # BLOCK ID DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE 6431 Fannin Houston, Texas 77030 DATE REQUESTED BILLING RESEARCH TEACHING Main Secretary 713-500-5324 Histology Lab 713-500-5363 Outreach Lab 713-500-5258 Electron Microscopy Lab 713-500-5280 Fax Number 713-500-0733 IHC Lab 713-500-5096 UT PATHOLOGY CASE # (SUXX-XXXX) REQUESTING PATHOLOGIST (Attending Pathologist's Name Necessary)

RESEARCH/ TEACHING ACCOUNT # (Request Will Not Be Accepted Without Billable Account #) TEST MENU PLEASE PLACE AN X NEXT TO THE TEST YOU WISH TO ORDER

EPITHELIAL MARKERS INFECTIOUS AGENTS PROLIFERATION/ BREAST PROGNOSTIC MARKERS/ AE1/ AE3 CAM 5.2 (CK8) Adenovirus MYOEPITHELIAL CK5/6 CK7 Cytomegalovirus (CMV) CK14 CK19 Epstein Barr Virus (EBV-LMP) P63 Ki67 SKp2 CK20 CK Pan Epithelial H. Pylori Membrane Antigen (EMA) HMWK Hepatitis B Core Antigen Pharmacodiagnostic Markers (34βE12) Hepatitis B Surface Antigen (FDA Approved) MOC31 Herpes Simplex Virus I & II (HSV) Human Papilloma Virus (HPV) Her-2-neu ER PR EGFR TUMOR ANTIGENS Parvovirus SV-40 T Antigen (Bk Virus) Alpha Fetoprotein (AFP) Toxoplasma β-Catenin Immunofluorescence BerEP4 LYMPHOID ANTIGENS/ MYELOID/ B72.3 (TAG-72) HISTIOCYTIC IgA IgG IgM C3 CA-19-9 CA-125 Cyclin D1 (Bcl-1) Bcl-2 Bcl-6 Calretinin Kappa Lambda Pre-albumin C1q Kappa Lambda CEA (mono) CEA (poly) CD1a CD2 CD3 CD4 CD5 CDX-2 CD7 CD8 CD10 CD15 (Leu-M1) Fibrinogen Albumin C4d E-Cadherin CD20 CD23 CD30 (Ki -1) CD38 GCDFP (BRST-2) CD43 CD45 (LCA) CD54 CD56 Alport's Syndrome (1, 3, 5) Hepatocyte (Hepar-1) CD57 (Leu7) CD68 CD79a CD99 Inhibin MUC2 Other: CD117 (c-kit) CD138 p16 p53 p57 p504s (Racemase) ALK-1 Protein Alpha-1-Antitrypsin Placental-Like Alkaline Phosphatase (PLAP) Factor 13a Hemoglobin Lysozyme Prostate Specific Antigen (PSA) MAC387 Mast Cell Tryptase Chromogenic In-Situ Hybridization Prostatic Acid Phosphatase (PAP) Myeloperoxidase PAX-5 TdT Zap70 PTEN EBER-1 CPT Code- 88365 Renal Cell Carcinoma (RCC) ENDOTHELIAL CELL MARKERS Retinoblastoma Protein Kappa & Lambda Surfactant Protein B (SPB) CD31 CD34 D2-40 TTF-1 Factor 8 Related Antigen Other: Wilm's Tumor VEGF

INTERMEDIATE FILAMENTS/ MUSCLE NEURAL/ NEUROENDOCRINE/ MARKERS MELANOCYTIC MARKERS Fluorescence In-Situ Hybridization αSMA Adhalin Merosin Alpha-Synuclein Actin (MSA) Dystrophin Spectrin Amyloid A β-Amyloid Her-2-Neu CPT Code- 88365 Desmin Caveolin-3 MHC-Type1 Chromogranin A Myogenin Dysferlin SMI-311 Glial Fibrillary Acidic Protein (GFAP) Chromosomes: Human Melanoma (HMB45) Myoglobin Emerin C-term N-term Mid-Rod 7 8 13 Fast Myosin β-Dystroglycan γ-Sarcoglycan Mart-1 (Melan A) 17 20 X & Y C5b9 Neurofilament (NF) NSE Myosin Heavy Chain (SMMS-1) S100 Protein Neu-N Other: Vimentin Collagen Type IV Synaptophysin Tau-2 HORMONES/ GASTROINTESTINAL/ Tyrosinase Ubiquitin Other: PITUITARY SPECIAL INSTRUCTIONS: ACTH Calcitonin FSH Gastrin Glucagon GH HCG LH Insulin Prolactin Serotonin Somatostatin Thyroglobulin TSH