IMMUNOHISTOCHEMISTRY SUBMISSION FORM

Animal Health Diagnostic Center LAB USE ONLY College of Veterinary Medicine, Cornell University Histopathology Contacts Phone: 607-253-3319 AHDC Accession No./ Date In Partnership with the NYS Dept of Ag & Markets Fax: 607-253-3357 US Postal Service Address: FedEx/UPS Service Address: Web: https://ahdc.vet.cornell.edu PO Box 5786 240 Farrier Rd E-mail: [email protected] Ithaca, NY 14852-5786 Ithaca, NY 14853 A $5.00 fee is added to each accession to cover processing. IMMUNOHISTOCHEMISTRY TESTING & FEES Client $35.00 = Individual Antibody (IHCNO) Requested w/o Laboratory Histopathology Interpretation (Slides/Blocks Returned to Submitter. No Report Generated) Address $30.00 = Individual Antibody (IHCDX2) Requested with Histopathology Interpretation by a Cornell Pathologist City, State, Zip (Slides/Blocks Retained by Cornell University. Report Generated) Additional Fees for Histopathology Apply E-mail $110.00 = Leukocyte Panel (IHCLP) Requested with Phone Number Histopathology Interpretation by a Cornell Pathologist (Slides/Blocks Retained by Cornell University. Report Generated) FAX Number

Animal’s Name or No: Species: Tissues Submitted: Patient History:

 Provide 10 unstained slides for panels and 4 unstained slides for individual antibody requests per paraffin block.  Each antibody request will include staining of the test slide, positive control tissue, and a negative reagent control.

Test(s) Requested - Circle or place a check mark next to each antibody requested Leukocyte Panel (CD3/PAX5/CD20/IBA-1) CK20 Olig2 INFECTIOUS DISEASE ANTIBODIES CNPase CCHS Panel (CD3/PAX5/CK19/LTA/TLR-4) Parathyroid Adenovirus (canine) Adenocorticotropic Hormone (ACTH) Desmin Hormone PAX5 Borrelia burgdorferi α-antitrypsin E-cadherin PCNA BRSV (bovine) α-fetoprotein FoxP3 Periaxin BVDV (bovine) Gastrin Anti-Myelin Protein Zero PNL2 Coronavirus (Bovine) GFAP β-Amyloid Precurser Protein PROX1 Coronavirus (Canine/Feline) (FIP) β-catenin Glucagon PGP9.5 CDV (Canine distemper virus) βIII-tubulin HepPar1 S100 Cryptosporidium BLA.36 Insulin EEE (Request with Histopathology) Sarcomeric actin Calcitonin Iba1 EHNV (Ranavirus) Smooth muscle actin Calponin Inhibin EHV1&4 Calretinin Ki67 Somatostatin FCV (Feline calicivirus) CD3 Lipoteichoic acid SOX2 Herpesvirus (BHV-1/IBR) CD18 (Canine) Mac387 SSTR2 Herpesvirus (Feline) CD20 MAP2 Synaptophysin Leptospira CD45-B220 Melan-A Thyroglobulin Listeria CD45RA MUM1 TLR-4 Minute parvovirus (CPV-1) CD204 Muscle actin TTF1 Neospora CD31 Myeloperoxidase Uroplakin III Papillomavirus CD117 (c-kit) Myoglobin Vimentin Parvovirus/ Panleukopenia CD79a (Equine Only) NeuN vWF PED (porcine) Rotavirus Chromogranin A Neurofilament (70,160, 200 kDa) WT1 CK AE1/AE3 NSE (Neuron Specific Enolase) Toxoplasma CK7 WNV (Request with Histopathology) CK19 Signature of Referring Pathologist

Comments: ORG-WEB-015-V10