Immunodermatology Laboratory Department of Dermatology University of Utah Health Care 30 North 1900 East, 4A330 SOM Salt Lake City, Utah 84132 Dermatology Laboratory Directors: Kristin M. Leiferman, M.D. John J. Zone, M.D. Email: [email protected] IMMUNODERMATOLOGY REQUEST FORM - Serum Specimens 1. Patient Information 2. Billing Information Patient Name (Last, First, MI): Gender: Male Female Bill to: Insurance Patient Clinician Include copies of both sides of the patient’s insurance card(s) Insurance Name: Date of Birth (MM/DD/YYYY): Include copies of the patient’s demographic face sheet or write-in details below Insurance Address: City/State/Zip: Street Address: City: Zip: State: Subscriber Name: SS#: Patient Phone #: Policy #: Medical Record/Patient ID#: Subscriber DOB: Relationship to Subscriber: Self Secondary Insurance: Yes Spouse Dependent No Attach all of the patient’s secondary insurance information to this request form 3. Requesting Physician/Clinic Information Clinic Name: Address: City: Requesting Physician: State: Zip: Requesting Physician NPI#: Phone: Requesting Physician Signature: Fax: 4. Serum Specimens Serum Collection Date: _____ / ______ / ____ For Tissue Specimens, please use Tissue Request Form SERUM ANTIBODY TESTING IFA & ELISA Please do not send whole blood CLINICAL DIAGNOSIS AND HISTORY: For information on which test(s) to order, please refer to the instruction sheet, web page, or call for assistance. Pemphigoid Panel IgG & IgA Basement Membrane Zone antibodies IFA IgG BP 180 & IgG BP 230 antibodies ELISAs Pemphigus Panel IgG Cell Surface antibodies IFA IgG Desmoglein 1 & Desmoglein 3 antibodies ELISA IgA Pemphigus Antibodies IFA Paraneoplastic Pemphigus Antibodies IFA IgA Celiac Panel IgA Endomysial antibodies IFA IgA Tissue Transglutaminase (TG2) antibodies ELISA *Total Serum IgA Determination by Mininephelometry Pemphigoid (Herpes) Gestationis Factor IFA Epidermolysis Bullosa Acquisita Panel IgG & IgA Basement Membrane Zone antibodies IFA IgG Collagen VII antibodies ELISA Epithelial Antibody Screening Panel IgG & IgA Basement Membrane Zone antibodies IFA IgG & IgA Cell Surface antibodies IFA IgG BP 180 & IgG BP 230 antibodies ELISAs IgG Collagen VII antibodies ELISA IgG Desmoglein 1 & IgG Desmoglein 3 antibodies ELISAs IgA Dermatitis Herpetiformis Panel IgA Endomysial antibodies IFA IgA Tissue Transglutaminase (TG2) antibodies ELISA IgA Epidermal Transglutaminase (eTG/TG3) ELISA *Total Serum IgA Determination by Mininephelometry IgG Celiac/Dermatitis Herpetiformis Panel IgG Endomysial antibodies IFA IgG Tissue Transglutaminase (TG2) antibodies ELISA KITS NEEDED: (circle amount) LAB USE ONLY Accession # Date Received IFA: Indirect Immunofluorescence Assay ELISA: Enzyme Linked Immunosorbent Assay Basement Membrane Zone Antibody Panel IgG & IgA Basement Membrane Zone antibodies IFA IgG BP 180 & IgG BP 230 antibodies ELISAs IgG Collagen VII antibodies ELISA * performed on initial test, not repeated for subsequent test Check Panels OR Individual Tests Tech Initials 4 Kits 8 Kits 12 Kits ASAP? Other: Phone: (801) 581-7139 • Toll-Free: (866) 266-5699 • Fax: (801) 585-5695 • Web: immunodermatology.uofumedicine.org SEE REVERSE SIDE FOR TISSUE/BIOPSY SPECIMENS TEST ORDERING Immunodermatology Laboratory Department of Dermatology University of Utah Health Care 30 North 1900 East, 4A330 SOM Salt Lake City, Utah 84132 Laboratory Directors: Kristin M. Leiferman, M.D. John J. Zone, M.D. Email: [email protected] Dermatology IMMUNODERMATOLOGY REQUEST FORM - Tissue/Biopsy Specimens 1. Patient Information 2. Billing Information Patient Name (Last, First, MI): Gender: Male Female Bill to: Insurance Patient Clinician Include copies of both sides of the patient’s insurance card(s) Insurance Name: Date of Birth (MM/DD/YYYY): Insurance Address: Include copies of the patient’s demographic face sheet or write-in details below City/State/Zip: Street Address: City: Policy #: Zip: State: Subscriber Name: SS#: Patient Phone #: Medical Record/Patient ID#: Subscriber DOB: Relationship to Subscriber: Self Secondary Insurance: Yes Spouse Dependent No Attach all of the patient’s secondary insurance information to this request form 3. Requesting Physician/Clinic Information Clinic Name: Address: City: Requesting Physician: State: Zip: Requesting Physician NPI#: Phone: Requesting Physician Signature: Fax: 4. Tissue Specimens Biopsy Collection Date: _____ / ______ / ____ For Serum Specimens, please use Serum Request Form DIRECT IMMUNOFLUORESCENCE (DIF) Not acceptable for DIF – Formalin-fixed tissue ANATOMICAL SITE CLINICAL DIAGNOSIS AND HISTORY Fixative: MICHEL'S or ZEUS' MEDIUM Skin Mucosa Skin Mucosa FIXED TISSUE HISTOLOGY (H&E) Punch Shave Excision Sun Exposed Punch Shave Excision Sun Exposed Non Sun Exposed Non Sun Exposed Lesional Perilesional Uninvolved Lesional Perilesional Uninvolved Fixative: FORMALIN Not acceptable for H&E - Michel’s-fixed tissue Punch Shave Excision Punch Shave Excision EOSINOPHIL MAJOR BASIC PROTEIN (eMBP1) May be submitted in Formalin or Michel’s Medium eMBP1; eosinophil-derived neurotoxin (EDN) staining also performed KITS NEEDED: (circle amount) LAB USE ONLY Accession # Date Received Tech Initials 4 Kits 8 Kits 12 Kits ASAP? Other: Phone: (801) 581-7139 • Toll-Free: (866) 266-5699 • Fax: (801) 585-5695 • Web: immunodermatology.uofumedicine.org SEE REVERSE SIDE FOR SERUM SPECIMENS TEST ORDERING