Department of Anatomic Pathology

Department of Anatomic Pathology 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5 Phone: (416) 480-4600 Fax: (416) 480-4271

Request for Consultation on Breast Biomarkers For use by External Clients Only Referring Institution/Laboratory: (Please print) Referring Pathologist name:(Please print) Name & Address:

Phone: Fax: Email: Specimen number:

Slide(s): Block(s): 1. Markers requested: Accession number (SB Lab use only)  ER/PgR/HER2

 ER/PgR

 HER2

 Other, please specify

2. Specimen Fixation: a. Cold Ischemic time: b. Fixation time: c. Fixative:  10% NBF

 Decalcification and then 10% NBF (applies to some bone specimens)

 Alcohol based fixative and then 10% NBF (applies to most FNA specimens)

 Other______

3. Is this the first specimen tested for this tumor?  Yes

 No

 This is another focus from the same patient

4. If this is not the first specimen from this tumor, please provide the reason for re-testing:  Previously recommended

 Previously tested ER-ve or HER2-equivocal by both IHC and ISH

 Clinician request

Version 1.1 2015/07/17 Not a chart copy Page 1 of 2  Other (please specify)______

Submitting Pathologist Signature Date (yyyy/mm/dd)