 ACH  RGH  FMC  SHC MOLECULAR PATHOLOGY REQUISITION SEE PAGE 2 FOR ADDITIONAL INFORMATION PROVINCE  FMC - WHC * REQUIRED INFORMATION  PLC PERSONAL HEALTH NUMBER (PHN) MEDICAL RECORD NUMBER ___ ___ ___ ___ ___ - ___ ___ ___ ___ TBCC ∗ PROCEDURE PERFORMED IN: PATIENT LAST NAME  OR: ________________  CLINIC: ________________  OTHER: ______________ FULL FIRST NAME MIDDLE NAME PHYSICIAN TO ACT ON RESULTS: _______________________________ * Last Name PATIENT ADDRESS _________________________________ * Full First Name ____________________________________________________________________ * Office Address including city (Location Code) for Report Delivery CITY, PROVINCE CHART NUMBER GENDER DATE OF BIRTH PATIENT PHONE NUMBER __ __ __ __ / __ __ / __ __ For test results & related inquires contact Laboratory Information Centre (LIC) at 403-770-3600 Y * TISSUE REMOVED BY: (fresh tissue only)  SAME PERSON/LOCATION AS ABOVE Y M M D D (__ __ __) __ __ __ - __ __ __ __ ACCESSION NUMBER (Lab Use Only) ∗ DATE COLLECTED: _______________________________ __________________________________ Last Name Full First Name Y Y PO STAL CODE ___ ___ ___ ____ / ___ ___ ___ / ___ ___ Y Y Y Y M M M D D ____________________________________________________________________ Office Address including city (Location Code) for Report Delivery Phone/Pager #: __________________________ ADDITIONAL COPIES TO: 1) _____________________________ * Last Name __________________________ * Full First Name * Office Address including city (Location Code) for Report Delivery 2) _____________________________ * Last Name __________________________ * Full First Name * Office Address including city (Location Code) for Report Delivery ____________________________________________ Block(s) No.: Surgical Number: Specimen Type: ____________________________________________ Fixed Fresh/Frozen Tissue Formalin *Blood/BM Other Fluid Blocks Included? Yes No H&E(s) included? Yes No Flow Media Type Tissue/Fluid Source: * Blood specimens should be submitted in EDTA or ACD tubes Submitting Site: ACH FMC PLC RGH SHC Consult DSC Flow History/Diagnosis: Non-CLS Date of Test Request: YYYY-MMM-DD % malignant cells in indicated region/specimen ____ Lymphocyte Receptor Gene Rearrangement/Translocation PCR In Situ Stain Viral and Bacterial Pathogen Detection PCR In Situ Stain Immunoglobulin Heavy Chain Human Papillomavirus * T-Cell Receptor Herpes Simplex Virus (HSV 1 & 2) * Bcl-1 t(11;14) Varicella Zoster Virus Bcl-2 t(14;18) Epstein-Barr Virus IgH Somatic Hypermutational Status Cancer Genomic Alterations Cytomegalovirus * Parvovirus B19 (Please supply an H and E slide with blocks submitted for cancer genomic testing for assessment of tumor cellularity.) Mycobacterium tuberculosis Complex B-raf (V600) mutation Mycobacterium leprae IDH1/IDH2 mutation Human Polyomavirus (BK and JC) N-ras mutation (codons 12, 13, 61, 117, 146) Adenovirus * *research or education support only K-ras mutation (codons 12, 13, 61, 117, 146) **Oligodendroglioma – 1p/19q LOH NOTE: In Situ tests are to be interpreted by the requesting Pathologist. **Microsatellite Instability MGMT Promoter Methylation EGFR mutation (e.g. lung cancer) EGFRvIII EGFR Amplification Human DNA Identity Testing ** Identity/Contamination Test **A sample of normal patient blood or tissue is required for comparison. Please phone 403-220-4240. See reverse (page 2) for instructions on submitting a specimen and shipping address. Mol Path # CLS Form# REQ9038AP 20140205 Laboratory Information Centre: 403-770-3600 www.calgarylabservices.com Page 1 of 2 Calgary Laboratory Services www.calgarylabservices.com Main Reception (403) 770-3500 Laboratory Information Centre 403-770-3600 Medical Staff: For test information, specimen collection instructions, etc. see www.calgarylabservices.com Physicians may contact the Laboratory Information Centre (L.I.C.) 403-770-3600 for test results and related inquiries FOR GENERAL CORRESPONDENCE: EMAIL [email protected] PROTOCOL FOR SUBMISSION OF TEST REQUESTS FROM NON-CLS LABORATORIES TO THE CLS MOLECULAR PATHOLOGY LABORATORY Frozen, fresh, or other perishable specimens: Please contact the Molecular Pathology Laboratory directly by phone at 403-220-4240 or fax at 403-270-0682 to arrange delivery of specimen. Fixed (paraffin-embedded or fixed cytology): 1. th Specimens must be sent to the Consult Desk, Calgary Laboratory Services, 11 floor Foothills Medical Centre: c/o Consult Desk, CLS AP/Cytology th 11 floor, Foothills Medical Centre th 1403 - 29 Street NW Calgary, AB T2N 2T9 Phone: Fax: 403-944-3965 403-944-4748 2. All specimens must be accompanied by a fully completed Molecular Pathology requisition. 3. Please note specimen requirements for the requested test. 4. Microsatellite Instability and Loss of Heterozygosity testing requires the cancer tissue to be paired with normal tissue or blood from the same patient. Specimen misidentification, floater, contamination, etc. requires comparison specimens to evaluate genetic identity. 5. Cancer genomic testing requires an H and E stained slide (tumor rich area clearly circled with a black marker) with the block sent for testing so the tumor cellularity can be evaluated. If tumor cellularity is low, a false negative result is more likely than if the tumor cellularity is high. 6. Please DO NOT send specimens or requests to the Laboratory Director, Dr. Demetrick. His office mail is handled externally from CLS and may be significantly delayed. CLS Form #REQ9038AP 20140205 Page 2 of 2