250 East Broadway, Maryville, TN 37804 (P) 865.380.9746 (F) 865.380.9191 Oncology Requisition (Toll Free) 800.932.2943 www.mplnet.com CLIENT INFORMATION ORDERING PHYSICIAN INFORMATION Account: Client: Ordering Provider Other Provider

Address: NPI NPI

City, State, Zip: Contact # Fax # Contact # Fax # Tel: Fax: PATIENT INFORMATION/CLINICAL INDICATION Name (Last, First) SSN: - - DOB: / / Sex: £ Male £ Female

Address (Street, City, State, Zip) Tel Patient ID

Other Patient ID Hospital ID Clinical Diagnosis/Reason for Referral Other ID

Previous Treatment(s) Diagnosis Codes (ICD) (required) £ CBC Included Dx1 ______Dx2 ______£ Pathology report included

BILLING INFORMATION SPECIMEN INFORMATION £ Client £ Insurance/Patient (Please Attach/Copy Insurance Info) Collection Date/Time Specimen/Block #

Insurance Company Policy/Group # £ Blood £ FNA £ Core Exhaust Block? £ Yes £ No

£ Bone Marrow £ CSF £ Slides POS Code (required) Source/Comments £ Fresh Tissue £ Pleural Fluid £ Other £ Hospital Inpatient £ Hospital Outpatient £ Physician Office

COMPREHENSIVE EVALUATIONS MPLN hematopathologists utilize our StrataFLEX™ (Strategic Reflex Testing) approach to laboratory medicine and will recommend only the most appropriate reflex testing. All clinically relevant findings and analysis are provided in an integrated report. q Bone Marrow Pathology Evaluation (BMPE) q Peripheral Blood or Other Tissues/Fluids - Flow and Morphology Evaluation (Flow M)

MOLECULAR ONCOLOGY FLOW CYTOMETRY

£ ABL G* kinase Gleevac® resistance £ FLOW leukemia/myeloma/lymphoma £ BRAF mutation analysis £ add a morphological comment to the report (FLOW M) £ FLT3* mutation analysis for ITD £ FLOW TC technical component only £ KRAS mutation, EGFR inhibitor response For limited/targeted markers, please check: £ NPM1* mutational analysis £ lymphoid markers only £ P BCELL Ig heavy chain gene rearrangement £ b-cell/plasma cell markers only (i.e., monoclonal gammopathy) £ reflex to P IGK kappa light chain if IGH negative £ minimal residual disease (please specify) ______£ P BCL2 t(14;18) gene rearrangement £ other (please specify) ______£ P EGFR EGFR mutation analysis For reflex testing ifFLOW positive for B-CLL clone £ reflex to F ALK if EGFR is negative £ FLOW ZAP70 £ P AML* mutation profile (FLT3 and NPM1) £ F CLL (FISH) reflex to CEBPA* testing if FLT3 and NPM1 negative £ FLOW PNH paroxysmal nocturnal hemoglobinuria (FLAER, CD14, CD24, £ P JAK2 V617F Ph negative chronic MPD CD59) £ P TCR t-cell receptor gamma gene rearrangement £ FLOW BAL bronchoalveolar lavage (CD4:CD8) £ P BCR ABL quantitative PCR major and/or minor £ FLOW LAD leukocyte adhesion (CD11a, CD11b, CD11c, CD18) CHECK if fusion type known £ major £ minor £ FLOW ZAP70 ZAP 70 Include most recent patient history regarding CML status and treatment £ FLOW CD4 t-cell subsets (CD3, CD4, CD8, CD4:CD8) £ P PML RARA* quantitative PCR long and/or short £ FLOW EX analysis (T-cell subsets, CD19, CD56) CHECK if fusion type known £ long £ short FISH

£ F AALL Adult: t(9;22), 11q23, t(12;21) CYTOGENETICS £ F BURKITT “double hit” lymphoma t(14;18), 3q27, 8q24 £ history of transplant Select One: £ male £ female £ F CLL p53, 11q22, 13q11/13q34-,+12,6q- £ F HER2 HER2/neu, CEP 17, 17q11.2q12 amplification £ CYTO BM marrow £ CYTO PB peripheral blood (Constitutional) £ F MDS -5/5q, -7/7q-, +8, 20q- £ CYTO LPB blood (Oncology) £ CYTO ST solid tumor tissues £ F MPD t(9;22), +8, 13q14, 20q-

£ CYTO LN lymphoma £ reflex JAK2 if t(9:22) neg £ F MM +5/+9/+15, 13q14, p53, t(11;14), 1q21 CIRCULATING TUMOR CELL DETECTION includes reflexF FGFR3 t(4;14), F IGH MAF t(14;16) if IGH rearranged (Use Only with MPLN CELLSEARCH Kit) £ F BCR ABL t(9;22) if negative Check one: £ breast £ colon £ prostate £ reflex JAK2 £ F PALL Pediatric: t(9;22), +4, +10, +17, 11q23, t(12;21) £ CELLSEARCH ENUMERATION ONLY £ F URO Bladder Cancer £ CELLSEARCH WITH PHYSICIAN INTERPRETATION COMMENTS

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