Requisition for Immunology Testing Client (Organization): ______

Suspect or known diagnosis: ______Patient Information: ______Name: ______ClinicalImmunology

– Birthdate: (YYYY/MM/DD): ___Sex:  Male  Female Referring Physician Information: Date Drawn (YYYY/MM/DD): ___ Name: ______Email: ______Lab Reference Specimen #: ___ Phone: ______

Test Request  Autoimmune Encephalitis Panel IIFA Vasculitis NMDAR, LGI1, CASPR2, AMPAR1/R2, GABARB1/B2, DPPX, GAD65 and IgLON5  ANCA (anti-MPO/anti-PR3) (ANCA) ELISA Current WBC count for specimen collected:  Serum (AEPS)  CSF (AEPCSF)  Anti-GBM (AGBM) ELISA Please fill out the Clinical Questionnaire and submit it with the patient’s sample. Clinical Anti-Cyclic presentaiton: Citrullinated Peptide (ACCP) ELISA  Paraneoplastic Antibody Panel  Anti-ds DNA by dsDNA-NcX Elisa (DNA) ELISA Hu, Yo, Ri, Ma2/Ta, Amphiphysin, CV2, recoverin, SOX1, titin, zic4, GAD65 and Tr (DNER)  Anti-GM1, IgM (AGM1) ELISA store and ship frozen  Serum (PNAS) IIFA, Immunoblot  CSF (PNACSF) IFFA  Anti-Histone Group (HIST) ELISA For serum samples titin and recoverin only done by Immunoblot testing.  Immune Complexes (CIC) ELISA LondonHealth Sciences Centre For CSF samples titin and recoverin are not available.  Anti-Tissue Transglutaminase, IgA (TTGAB) Chemiluminescence  Neuromyelitis Spectrum Profile IIFA Store & ship frozen Anti-Myelin Oligodendrocyte Glycoprotein and Aquaporin4 (MOG/AQP4)  C1 Inhibitor Protein (C1IN) ELISA  Serum (NMOSD)  CSF (NMOSDCSF)  CH50 (TCOMP) Turbidimetric  Anti-Gangliosides Profile, IgG and IgM (GAN) Immunoblot  Complement C2 (C2) RID Anti GM1, GM2, GM3, GD1a, GD1b, GT1b, GQ1b  IgG Subclasses (IGGSUB) IgG1, IgG2, IgG3 and IgG4 Turbidimetric  Chromosome Profile (ANACP) Immunoblot  Serum Free Light Chains (FLC) Turbidimetric dsDNA, Nucleosomes, Histones, DFS70, Scl-70, CENP A, CENP B Galactomannan Aspergillus Antigen ELISA  ENA Profile (ANAEPP) Immunoblot  Galactomannan Aspergillus Antigen Serum (GALACTOM) nRNP/Sm, Sm, SS-A, BB-B, Ro-52, Scl-70 and Jo-1  Galactomannan Aspergillus Antigen BAL Fluid GALACTOMF)  Liver Profile (ANALP) Immunoblot  Anti-Nuclear Antibodies (ANA) IIFA M2, M2-3E, Sp100, PML, gp210, LKM-1, LC-1, SLA/LP and Ro-52 For certain patterns immunoblot follow up with either or:  Myositis Antibodies Profile (.MYOAP) Immunoblot Chromosome profile, ENA profile for titres ≥1:160 Anti-Mi-2α, Mi-2β, TIF1γ, MDA5, NXP2, SAE1, Ku, PM-Scl 100, PM-Scl 75, Jo-1,  Autoimmune Liver Disease Profile (AILDP) IIFA SRP PL-7, PL-12, EJ, OJ and Ro-52 AMA, ASMA, LKM and ANA  Systemic Sclerosis Profile (.ANANP) Immunoblot For certain patterns immunoblot(s) follow up with either or: Scl 70, CENP A, CENP B, RP11, RP 155, Fibrillarin, NOR90, Th/To, PM-Scl75 Chromosome profile, ENA profile for titres ≥1:160 PM-Scl 100, Ku, PDGFR, Ro-52 Liver Profile for titres ≥1:80

SPECIMEN REQUIREMENTS AND SHIPPING INSTRUCTIONS Sample: Ship to: CSF or Serum, 1 mL: Send in a small 12x75 or 13x75 mm polystyrene tube. LHSC, Victoria Hospital Samples should arrive before Friday 3 pm. Do not send samples to arrive on weekends or holidays. Sample Reception, Room D1-206 Ship Anti-GM1 and TTGAB frozen with dry ice. All other samples can be shipped with ice packs. 800 Commissioners Rd East London, ON N6A 5W9

For individual test pricing go to REQUEST FOR SERVICES - CLINICAL LABORATORIES and fill out the form to get a quote.

LHSC, Victoria Hospital Clinical Immunology Laboratory, B10-236 800 Commissioners Rd East London, ON, N6A 5W9 Phone: 519-685-8500 ext. 33097 │ Fax: 519-663-3704