IMMUNOHISTOCHEMICAL REQUEST FORM LAB USE ONLY 350 W. 11th Street, Rm 4001A Date In: Indianapolis, IN 46202-4108 Date Out: 317-491-6326 Total Slides: Please check one: Inpatient Outptient Ambulatory Surg Center

PATIENT NAME: DATE OF BIRTH:

COLLECTION DATE: ACCESSION #:

CLIENT NAME: BLOCK #: REQUESTED BY: OUTSIDE CASE #: PLEASE CIRCLE ALL REQUESTED ABS EPITHELIAL ( Markers ) MESENCHYMAL (Sarcoma Markers) □ Vasoact Int Polypeptide (VIP) (poly) □ TIA-1 □ (AE 1/3) □ a-1-Antichymotrypsin (a-1-ACT) (poly) □ ACTH (poly) □ Tartrate-Resistant Acid ( TRAP) □ Keratin (CAM5.2) □ a-1-Antitrypsin (a-1-AT) (poly) □ Growth Hormone (GH) (poly) □ Tryptase (AA1) □ Keratin Cocktail □ Amyloid A Alpha C3 □ Foll Stim Hormone (FSH) (poly) □ Keratin (34BE12) □ (1A4) (smooth muscle specific) □ Thyroid Stim Hormone (TSH) (poly) (HMB45) □ Keratin #8 (35BH11) □ Actin (HHF35) □ Prolactin (poly) □ MYF4 (Rhabdomyosarcoma) □ /6 (D5/16B4) □ CD31 (JC/7DA) □ HBME-1 (Mesothelial Cell) □ Keratin (poly — wide spectrum ) □ Collagen IV (CIV22) HEMATOPOIETIC □ MELAN A (A103) □ Keratin #7 (OV-TL 12/30 ) □ (D33) □ CD1a (010) □ Microphthalmia Ab-2 □ (CBL 197) □ Factor VIII (von Willibrands) (poly) □ CD2 (LFA-2) □ CD63 9NK1/C3) □ Keratin #18 (DC10) □ Factor XIIIa (poly) □ CD3 (poly) □ Tyrosinase (T311) □ Keratin #19 (BA17) □ Lysozyme (Muramidase) (poly) □ CD4 (1F6) □ MyoD1 (5.2F) □ Keratin #20 (Ks20.8) □ Myoglobin (poly) □ CD5 (CD5/54/B4) □ Myogenin (F5D) □ CEA (11-7) □ Podoplanin / D2 40 □ CD7 (272) □ CEA (poly) □ (V9) □ CD8 (C8/144B) EMBRYONAL □ EMA (E29) □ Caldesmon (h-CD) □ CD10 (CALLA) □ a-1-Fetoprotein (ZSA06) □ Ber-EP4 □ Glypican III (1G12) □ CD15 (C3D-1—Leu-M-1) □ a-1-Fetoprotein (poly) □ Epidermal Recept (H11 ) □ Carbonic Anhydraise XI □ CD20 (L-26) PAN B □ Hepatocyte Specific Antigen-HSA □ ERA (MOC-31) □ CD21 (1F8) □ Plac Alkaline Phos (PLAP) (8B6) □ E-Cadherin (ECH-6) Neural/Neuroendocrine □ CD23 (1B12) □ Plac Alkaline Phos (PLAP) (poly) □ Fli-1 (C-19) □ Chromogranin A (poly) □ CD25 (4C9) □ Hum ChorioGontropin (HCG) (poly) □ CA125 (KS20.8) □ Chromagranin (K2H10) □ CD30 (Ber H2) □ Hum Plac Lactogen (HPL) (poly) □ CDX2 (CDX2-88) □ Panel □ CD34 (QBEnd10) □ Dysferin □ CD35 (Ber-MAC-DRC) VIRAL BREAST □ B □ CD42b (GPlb) □ Adenovirus □ a-Lactalbumin (poly) □ Emerin □ CD43 (DF-T1) □ BK Virus (BK-T1) □ Androgen Receptor (F39.4.1 ) □ Glial Fibr Acid Prot (poly) □ CD45RA (4k B5) □ C4d □ Bcl-2 (124) □ HBA.71 (013) Ewing’s, CD99 □ CD45RO (UCHL-1) PAN T □ CMV (CCH2&DDG9) □ BRST-2 (D6) □ InI-1 (H-300) □ CD45RB (PD 7/26) □ EBV (Imp) (CS1-4) □ BRST-3 (B72.3) □ Merosin □ CD54(ICAM-1) □ HHV-8 (ORF-73) □ Calponin CALP □ Neu-N □ CD56 (1B6) □ Helicobacter □ C Kit (CD117) □ (2F11) □ CD57 (HNK-1) Leu-7 □ Hepatitis B core Ag (poly) □ C-myc (9E11) □ Nerve Growth Fact (ME20.4) □ CD61 Y2/51 □ Hepatitis B surface Ag (poly) □ Estradiol □ NSE Poly □ CD68 (PG-M1) □ Herpes I (poly) □ Receptor (ER) (Sp1) □ PGP 9.5 ( Product □ CD68 (KP1) □ Herpes II (poly) □ Hercep Test (Her2) □ S-100 (poly) □ CD74 (LN2) □ Hum Papillomavirus (HPV) (poly) □ Inhibin □ S-100 A6 □ CDw75 (LN1) □ Parvovirus (B 19) □ Ki67 (MIB-1) □ Sarcoglycan Panel □ CD79a (mb-1) (JCB117) □ Spirochete □ Lewis-Y (BG-8) □ Serotonin (poly) □ CD123 □ Mammaglobin 304-1A5 □ □ CD138 (Syndecan) OTHER □ Progesterone Receptor (PR) (636 ) □ Synaptophysin (poly) □ CD146 (MEL-CAM) □ Muc 1 (Poly □ P53 (DO-7) □ Synaptophysin (SV 38) □ CD163 10D6 □ Muc 2 ( Ccp58) □ Epithelial Antigen (Ber-EP4 ) □ Laminin (4c7) □ CD 176 (Thomsen-Friedenreich □ Muc 4 (8G-7) □ WT1 Wilms Tumor (6F-H2) □ Myotilin (RS034) □ ALK Protein (Alk-1) □ Muc 5 (CLH2) □ VEGF □ Beta Amyloid 6F/3D □ Bcl-6 (P1F6) □ Muc 6 (CLH5) □ (KNY-379) □ Cyclin D1(Bcl-1) □ Calretinin PROSTATE □ Olig 1 □ FASCIN (55k.2) □ Dolichos (Lectin) □ Prostate Specific Antigen (poly) □ Olig 2 □ Glycophorin A(JC159) □ Peanut (Lectin) □ Prostate Acid Phosphatase (poly) □ Alpha- Synuclein (syn205) □ Hairy Cell (DBA.44) □ PCNA (PC10) □ P63 (JUL) □ Ubiquitin □ Hemoglobin (poly) □ Soybean (Lectin) □ Testosterone (poly) □ TAU (TAU2) □ (MAC 387) □ Ulex Europaeus agglutinin I (lectin) □ Pin 4 Cocktail □ AT 100 □ Myeloperoxidase (poly) □ Unstained slides _____ (#) □ P501 S □ MLH-1 ( G168-15) □ Pax 5 □ H&E stains _____(#) □ P504 S □ MSH-2 □ IgA (poly) □ Smoothelin R4A □ Uroplakin III (Aul) □ MGMT MT3.1 □ IgD (poly) □ SMED 4(Dpc 4) □ GATA 3 (HG3-31) □ PAKT □ IgG (poly) □ TFE-3 (T-16) □ PS6 □ IgM (poly) □ Nanog (aa 153-305) □ PH3 (Ser-10) □ IgG-4 1. 10% Formalin is the preferred □ Pax 2 ( Poly) □ PTEN (11G8.1) □ Kappa (poly) fixative for paraffin blocks. We □ MApk □ Lambda (poly) cannot guarantee results if any ENDOCRINE □ Anti-Perforin other fixative is used. □ Calcitonin (poly) ENDOCRINE (Pituitary) □ Bcl-6 (P1F6) □ Thyroglobulin (poly) □ Bob-1 (SC-955 2. Use positive charged slides when □ Gastrin (poly) submitting slides only. □ Parathyroid Hormone (poly) □ Glucagon (poly) □ Lat (Poly) □ TTF-1 8G7G3/1 □ Insulin (poly) □ Plasma Cell (vs38c) 3. Methanol, 95% Ethyl or Formalin □ GLUT-1 (SPM 498) □ Pancr Polypeptide (PPP) (poly) □ Tdt (poly) is the is the preferred fixative for □ Sox 2 Poly □ Somatostatin (poly) □ Thrombomodulin cytospins, aspirate smears, etc. □ S100 (16)