2023 New Lab Registration – CPQA-AQCP Form Submissions

CPQA-AQCP Form Submissions

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2023 New Laboratory Registration (all prices in CAD)

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All fields are required unless indicated otherwise

Laboratory Name

Of the representative submitting these subscription edits

Laboratory Phone Number

Mailing Address

Physical slides will be sent to this address.

Billing Address (if different than mailing address) (optional)

Please provide billing contact name and email if possible.

Technologist Name

Technologist Email

Pathologist Name

Pathologist Email

2023 IHC Subscriptions Available: (optional)

H&E (2 x $100; assessment of fixation, mounting, sectioning and staining of YOUR OWN H&Es)

Prostate p63 ($150)

Prostate AMACR ($150)

Prostate basal epithelial keratin; $150)

Gastric HER2 IHC (2 x $200)

HMB45 ($200)

PD-L1 (2 x $200; technical assessment only)

MMR ($500)

HSV ($200)

ER ($200)

PR ($200)

HER2 Breast IHC (No fee courtesy of AstraZeneca; emphasis on HER2-low)

c-Myc lymphomas ($250)

pan-TRK IHC ($300)

BRAFV600E ($250)

ROS1 ($200; technical assessment)

p53 endometrial ($200)

Chromogranin A ($200)

p16 ($250)

CK20 ($200)

CD117 ($250)

CD20 ($250)

Synaptophysin ($200)

ALK in NSCLC ($250)

Ki67 in breast ($250)

Calretinin ($200)

IDH1 R132H ($250)

ATRX ($250)

p53 vulvar ($250)

If p63/AMACR/prostate basal epithelial keratin were selected above, how many unstained slides do you require? (optional)

1 unstained slide (e.g. triple stain)

2 unstained slides (e.g. one double stain + one single stain)

3 unstained slides

Pricing of $150 applies to each unstained slide required.

2023 ISH Subscriptions Available: (optional)

Gastric HER2 ISH ($25)

ALK ISH ($25)

Breast HER2 ISH ($25)

1p19q FISH ($25)

2023 Molecular EQA Subscriptions (tentative pending recruitment) (optional)

Colorectal cancer ($500)

Can you provide a PO number?

Yes, I can provide it now.

No, I need an estimate from the CPQA before generating a PO.

PO Number (optional)

If you answered "yes" to the questions above.

Other comments (optional)

If you run multiple clones for a biomarker (e.g. PD-L1 or HSV) or separate assays (e.g. CEP17 and HER2 ISH), indicate so here and multiple slides can be sent if requested. Please note that optimization assistance for any above subscriptions is included (i.e. our samples can be used for EQA and validation).