Gender: M F
Requisition Number:Your Specimen Number:__________________
Pick Up Confirmation #:__________________
LIST OF DISEASES & FINDINGS
Fax: 201.599.9066
Fax: 866.369.411425 Riverside Drive, Suite #2, Pine Brook, NJ, 07058 www.siparadigm.com
DISEASES & FINDINGSHEMATOLOGIC
ALL ( MRD)MDSAML ( LLC MRD)
MPNCML, Follow-up CML, New diagnosis
Myeloma ( MRD) Hodgkin Lymphoma
Marrow infiltration
Anemia
STAT/ RUSH
LEVEL OF SERVICE
Complete Consult: Hematopathologistselects clinically pertinent tests
Perform marked tests only (Results with interpretation)
Technical Only (Results without interpretation) Call us to discuss appropriate testing
siPortfolio
SPECIMEN INFORMATION
Collection Date:
Sent Date:
Time:
CBC results attached
HEMATOPATHOLOGY TEST REQUISITION FORM (INFORMATION WRITTEN IN RED IS MANDATORY)
BILLING INFORMATION
Insurance
Hospital Outpatient
Client Patient Hospital Inpatient
PATIENT INFORMATION
Name:
DOB: (mm/dd/yy)
Street:
City: State: ZIP:
Med Rec #/ Patient ID/SSN #: Phone #:
PHYSICIAN INFORMATION
Referring MD:
MGUSLymphoma (NHL)
PNH
Atypical WBCs Eosinophilia Erythrocytosis LeukocytosisLeukopenia Lymphadenopathy Lymphocytosis Thrombocytopenia Thrombocytosis
Other:
List individual antibodies in clinical information box above (menu on back)
IMMUNOHISTOCHEMISTRY (IHC & CISH) siPortfolio-CYTO
FLOW CYTOMETRY
Myeloid Lymphoid Karyotyping
FISH ALL AML CLL CMLLPD MDS MPN
EosinophiliaMyeloma
Lymphoma:
Acute Leukemia
LGL (T/NK)
LPD
ALL ( MRD)
AML CLL ( MRD)
Hairy Cell Leukemia
LPL (Waldenström) Lymphoma ( B T) Lymphocyte subsets MDSMPNMyeloma ( MRD) PancytopeniaPNH
MOLECULARHematology NGS Panels
Pan-Myeloid Panel Pan-Lymphoid Panel (17 Genes)
JAK2 V617F with reflex to Exons 12, 13 and 15JAK2 V617F with reflex to CALR & MPL
Individual Genes
JAK2 V617F with reflex to CALR, MPL & 69 Gene NGS Panel
Reflexes
CLINICAL INFORMATION
ICD-10
Authorized Signature: Date:
The undersigned certifies that he/she is licensed to order the test(s) listed below and that such test(s) are medically necessary. By signing below, I have obtained patient’s informed consent for the requested tests.In case of Solid Tumor testing, the signature below authorizes the release of the patient’s specimen block/slides from its collection (holding) facility.
Non-Hospital Patient
Call resultsNeed results by: --- / --- / ------
L A S T F I R S T,
LIST OF INDIVIDUAL TESTSCYTOGENETICS
siPortfolio-MOLECULAR
siPortfolio-IHC
siPortfolio-FLOW
69 Genes (40 DNA & 29 RNA)
Attach clinical notes, patient information & copies of both sides of insurance card
MMR
Fixation Time: Fixative: Cold Ischemia Time:
Predictive/prognostic hormonal markers
ERPgRKi-67
HER-2/neu, IHCHER-2/neu, FISHHER-2/neu IHC with reflex to FISH Burkitt
Mantle
MZL/MALTDLBCL
WaldenströmFollicular
BCR-ABL Major, Quantitative with reflex to MinorBCR-ABL Major, Quantitative with reflex to ABL-Kinase Mutation
BCR-ABL Major, Quantitative with reflex to Minor & ABL-Kinase Mutation
Account Information:
(See complete menu on back of requisition)
AML
CML
CMML
CNL
ET
JMML
MDS
MPN
CLLB-Lymphoproliferative disorderB-Lymphomas
Waldenström
P.vera
PMF
Mantle
Continental US: Tel: 888.599.LABS(5227) PR/International: Tel: 888.782.5430
ABL Kinase Mutation (CML)
BCR-ABL, Major (CML)
BCR-ABL, Minor (ALL)
B-Cell Gene Rearrangement
BRAF
CALR
CEBPA
IGHV
FLT3
JAK2 Exon 12
JAK2 V617F
JAK2 Exons 13 & 15
MPL
MYD88
NOTCH1
NPM1
T-Cell Gene Rearrangement
TP53
PML-RARA
cKIT
SF3B1
PD-L1 22C3 FDA (KeytrudaTM)PD-L1 28-8 FDA (OpdivoTM)PD-L1 SP142 FDA (Tecentriq TM)
Other:
Other:
Other:
Bone Marrow, (tube #) ( )Fresh Tissue/Fluid, (tube #) ( ) Formaline Container # ( )Urine Containers #
Peripheral Blood, (tube #) ( )Site:Paraffin Blocks # ( ) Slides # ( )Other # ( ) Specify: ( )
F001
-01
DETAILED MENU: PLEASE DO NOT MARK ON THIS PAGE
1p36/1pTEL/1q25
ALK (Break Apart)
ATM/TP53
BCL2/IGH
BCL6 (Break Apart)
BCR/ABL
BIRC3/MALT1
CBFB (Break Apart)
CEP12/D13S319/13q34
CEP15
CEP3
CEP8
CEP9
CEPX/CEPY
CSF1R/D5S23:D5S721
D13S319/13q34
D20S108
D7S486/CEP7
ETV6 (Break Apart)
ETV6/RUNX1 (TEL/AML1)
FGFR1 (Break Apart/ Amp.)
FIP1L1/CHIC2/PDGFRA
HER-2/neu (PathVysionTM)
IGH (Break Apart)
IGH/CCND1
IGH/FGFR3
IGH/MAF
IGH/MAFB
IGH/MYC/CEP8
MLL (Break Apart)
MYB
MYC (Break Apart)
TP53
PDGFRB (Break Apart)
PML/RARA
RUNX1T1/RUNX1 (ETO/AML1)
AFB Alcian Blue Alcian Blue/PAS Amyloid Giemsa
PAS (Fungus) GMS H&E Iron Mucicarmine
Pap PAS diastase Reticulum Trichrome Wright Giemsa
Fusion Driver Genes (29)
ABL1
ALK
BCL2
BRAF
CCND1
CREBBP
EGFR
ETV6
FGFR1
FGFR2
FUS
HMGA2
Full Genes (17)U2AF1
WT1
ASXL1
BCOR
CALR
CEBPA
ETV6
EZH2
IKZF1
NF1
PHF6
PRPF8
RB1
RUNX1
Actin (muscle spec.)
Actin (sm. muscle)
ADH-5
ALK-1
CA 125
CA 19.9
Caldesmon
Calponin
Calretinin
CAM 5.2 (CK8/18)
CD1a
CD2
CD3
CD4
CD5
CD7
CD8
CD10
CD15
CD20
CD21
CD23
CD30
CD31
CD34
CD43
CD45 (LCA)
CD56
CD57
CD61
CD68
CD71
CD79a
CD99
CD117
CD138
CDX2
CEA, Monoclonal
CEA, Polyclonal
Chromagranin A
CK5/6
CK7
CK17
CK19
CK20
CK903
CMV
C-MYC
D2-40
Desmin
EBER (ISH)
E-Cadherin
Estrogen Receptor (ER)
Fascin
FVIII (von Willebrand)
FXIIIa
GATA3
GCDFP-15
GFAP
Glycophorin A (CD235)
Glypican-3
Granzyme B
H. pylori
HBME-1
Hepatocyte (HepPar1)
HER-2/neu
HHV-8
HMB45
HNF1ßHPV-HR
HPV-LR
HSV-1
HSV-2
IgA
IgG4
IgG
IgM
Inhibin
Kappa (IHC)
Kappa (ISH)
Ki-67
Lambda (IHC)
Lambda (ISH)
Lysozyme
Mammaglobin
Melan A
MiTF-1
MOC-31
MUM-1
Myeloperoxidase
MLH 1
MSH 2
MSH 6
Napsin A
NSE
OCT2
OCT4
PMS2RCC
S100
SMMS-1SOX-10
SOX-11Synaptophysin
TdT
Thrombomodulin
Thyroglobulin
TIA-1
TRAP
TTF-1Tyrosinase
Uroplakin-IIIVimentinWT-1
Expression Genes (5)
MLLT3
NUP214
PDGFRA
PDGFRB
RARA
RBM15
RUNX1
TCF3
TFE3
BAALC
MECOM
MYC
SMC1A
WT1
ABL1
BRAF
CBL
Hotspot Genes (23)CSF3R
DNMT3A
FLT3
GATA2
HRAS
IDH1
IDH2
JAK2
KIT
KRAS
MPL
MYD88
NPM1
NRAS
PTPN11
SETBP1 SH2B3
STAG2
TET2
TP53
JAK2
KMT2A (MLL)
MECOM
EBER (EBV) Kappa (ISH)
HPV (HR & LR) Lambda (ISH)
SPECIAL STAINS
FLOW CYTOMETRY MENU
IN SITU HYBRIDIZATION (ISH)
FLUORESCENCE IN SITU HYBRIDIZATION (FISH) MENU
PAN-MYELOID NGS PANEL (69 GENES)
IMMUNOHISTOCHEMISTRY (IHC) MENU
SF3B1
SRSF2
ZRSR2
MET
MLLT10
PAN-LYMPHOID NGS PANEL (17 GENES)ATM BTK BIRC3 CARD11 CD79B DDX3XFBXW7 MAPK1 MYD88 NOTCH1 PIK3CA
PIK3CD
PTEN
PTPN6 SF3B1 TP53 XPO
MYH11
MYBL1
NTRK3
www.siparadigm.com Fax: 201.599.9066
Fax: 866.369.411425 Riverside Drive, Suite #2, Pine Brook, NJ, 07058
IGHV
HEREDITARY CANCER NGS PANEL
SOLID TUMOR NGS PANEL
PLEASE USE THE DEDICATED HEREDITARY CANCER REQUISITION
PLEASE USE THE DEDICATED SOLID TUMOR REQUISITION
PCM1/JAK2
CD1aCD2CD3CD4CD5
CD26CD27CD28CD30
CD33CD105CD117CD123CD138
CD200CD71cCD79aCD79bCD81
CD103CD58CD59CD61CD64
CD65CD45CD49dCD52CD56
CD57CD34CD36CD38CD41
CD43CD20cCD22CD23CD24
CD25CD13
CD14CD15CD16
CD19CD7CD8CD10CD11bCD11c
CD235a (Glyco)
FLAERHLA-DRcIgA
cIgGcIgMKappa
cMPO
nTdT
ZAP-70
UroVysionTM Bladder Cancer
ALK Break Apart NSCLC
ROS1 Break Apart NSCLC
(IMMUNOHISTOCHEMISTRY)
Continental US: Tel: 888.599.LABS(5227) PR/International: Tel: 888.782.5430
TCR γ/δ TCR α/ß
LambdacKappa
cLambdacCD13
p16
p40
p504S
p53
p57
p63
p120 Catenin
PAX-5
PAX-8
PCK (AE1/AE3)
PD-1
PD-L1 (22C3)
PLAP
PSAPSAPPSMA
PgR Progesterone receptor
PIN4
PD-L1 (28-8)
PD-L1 (SP124)
Annexin A1
Arginase
B72.3/TAG-72
bcl-1
bcl-2
bcl-6
BerEP4
Beta HCG
Bg8
Bob.1
Alpha-1 fetoprotein (AFP)
Amyloid-A
BRAF
ALK (D5F3)
F001
-01
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