<p>Department of Anatomic Pathology 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5 Phone: (416) 480-4600 Fax: (416) 480-4271 </p><p>Request for Consultation on Breast Biomarkers For use by External Clients Only Referring Institution/Laboratory: (Please print) Referring Pathologist name:(Please print) Name & Address: </p><p>Phone: Fax: Email: Specimen number: </p><p>Slide(s): Block(s): 1. Markers requested: Accession number (SB Lab use only)  ER/PgR/HER2</p><p> ER/PgR</p><p> HER2</p><p> Other, please specify</p><p>2. Specimen Fixation: a. Cold Ischemic time: b. Fixation time: c. Fixative:  10% NBF</p><p> Decalcification and then 10% NBF (applies to some bone specimens)</p><p> Alcohol based fixative and then 10% NBF (applies to most FNA specimens)</p><p> Other______</p><p>3. Is this the first specimen tested for this tumor?  Yes</p><p> No </p><p> This is another focus from the same patient</p><p>4. If this is not the first specimen from this tumor, please provide the reason for re-testing:  Previously recommended</p><p> Previously tested ER-ve or HER2-equivocal by both IHC and ISH</p><p> Clinician request</p><p>Version 1.1 2015/07/17 Not a chart copy Page 1 of 2  Other (please specify)______</p><p>Submitting Pathologist Signature Date (yyyy/mm/dd)</p>