MOLECULAR PATHOLOGY REQUISITION

 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
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