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MOLECULAR PATHOLOGY CORE LABORATORY SERVICE REQUEST FORM 593 Eddy Street, Aldrich Bldg., 6th Floor, Providence, RI 02903
Phone: 401-444-5849 | FAX: 401-444-8741 | E-Mail: [email protected] Website: https://bit.ly/2NGsRXf
Requested by: (Name, email, phone)
PI/Department/ Institution
IRB/IACUC Protocol #: Billing Contact:
Cost Center / PO #: Req Date: PI Approval Signature: Date:
SPECIMEN TYPE PROVIDED ☐ Fixed (submitted in 70% ethanol) ☐ Paraffin block(s) ☐ Mouse tissue☐ Fixed (submitted in formalin) ☐ Frozen block(s) ☐ Human tissue☐ Fixed, other: _____________________ ☐ Unstained slides ☐ Other: ___________________☐ Unfixed / Fresh tissue ☐ Bone / Cartilage tissue present (needs decalcification)
REQUESTED SERVICES Histology: ☐ Cassette/Process/Embed – Paraffin
☐ Cassette/Process/Embed & Section – First slide☐ Process/Embed Only – Paraffin (tissues submitted in cassettes)☐ Unstained Sections: ______ Sections per block (if possible) ☐ Serial sections needed
Thickness (4 micron is standard if unchecked): ☐ 4µm ☐ 5µm ☐ 10µm ☐ ____ µmBake slides (routine is to bake at 60⁰C for 1 hour): ☐ YES ☐ NO
Staining: ☐ H&E ☐ Oil Red O ☐ TUNEL/ELISA☐ Trichrome ☐ PAS ☐ Other: ____________________________________
IMMUNOHISTOCHEMISTRY Antibody: ☐ Supplied by Investigator
Antibody: ____________________ ☐ Monoclonal, Clone: ___________ ☐ PolyclonalHost: _______________________
Source, Catalog number: _____________________________________________________
☐ Supplied by lab (contact lab for availability and pricing)
Staining Method: ☐ Automated Staining – Ventana XT ☐ Manual Staining – Dako Manual Enivision+ Kit☐ Protocol Optimization ☐ Protocol Supplied by Investigator
TISSUE MICROARRAYS Creation of TMA Block: ☐ Tissue provided by Investigator (Area of Interest Identified)
☐ Tissue provided by Investigator (Area of Interest NOT Identified)☐ Custom TMA (Tissue provided by Lifespan Tissue Bank)
TMA Histology: ☐ Unstained Sections: _______ sections per block Thickness (4 micron is standard if unchecked): ☐ 4µm ☐ 5µm ☐ 10µm ☐ ____ µm Bake slides (Routine is to bake at 60⁰C for 1 hour): ☐ YES ☐ NO
Staining: ☐ H&E ☐ Oil Red O ☐ TUNEL/ELISA☐ Trichrome ☐ PAS ☐ Other: ___________________________________
APERIO SCANSCOPE
Number of slides: __________________________ ☐ 20X ☐ 40X☐ Image Analysis Service Needed
Return form to [email protected]
(Name, email, phone & address)
