Link to Instructions

INFORMATION FORM - NON-PROFIT RESEARCH STUDY

Client: Pet Name:
Veterinarian: Vet. Phone: Vet. Fax:
Vet. Address:
Client Phone: Client Fax for a copy of the report :
Breed: Sex (circle):   F   FS   M   MN Age: Weight:
Reason for Test and Brief History (If you need more space, please use other side):
On Medication (circle one)   YES   NO  If yes, brief list:

X

Check tests desired and enclose appropriate fees: Cost
  Thyroid Profile 5 PLUS (T4, Free T4, T3, Free T3, TGAA - PLUS CBC, Differential,  Chemistries) ****IMPORTANT*** If on thyroid meds draw blood 4 - 6 hours after med and note dosage and hours here ===> DOSE: ______mg; HOURS: ______  $125.00
Thyroid Profile 5 (T4, Free T4, T3, Free T3) ****IMPORTANT*** If on thyroid meds draw blood 4 - 6 hours after med and note dosage and hours here ===> DOSE: ______mg; HOURS: ______  $75.00
Thyroid Profile 4 PLUS (T4, Free T4, T3, Free T3 - PLUS CBC, Differential,  Chemistries)
****IMPORTANT*** If on thyroid meds draw blood 4 - 6 hours after med and note dosage and hours here ===> DOSE: ______mg; HOURS: ______ 
$115.00
Thyroid Profile 4 (T3 and T4, Free T3 and T4) ****IMPORTANT*** If on thyroid meds draw blood 4 - 6 hours after med and note dosage and hours here ===> DOSE: ______mg; HOURS: ______ $64.00
CBC, Differential & Superchem (includes Liver Enzymes) #SA020 $62.00
SuperChem only (no CBC or Dif.) #SA010 $56.00
  Urine Bile Acid Test #85645 $52.00
  Blood Serum Bile Acid Tests  #T220 - Pre and post eating $43.00
  Phenobarbital Profile #5624  ****IMPORTANT*** Number of hours between giving Phenobarbital and blood draw _______ $64.00
  Potassium Bromide Profile #16120 $74.00
 

Dr. Dodd's Consultation Request Only. (Attach All Lab or Medical Information). 

            Deductible Donation to Non-Profit HEMOPET ====>

$45.00
  Other Tests (please list)

$          

  Total:  

$          

Checks should be made to HEMOPET. Enclose your check, blood sample(s) and this form in a small, well cushioned box. 

For credit card payments (all major cards accepted except Discover), include account number, expiration (mm/yy), name (as it appears on the card) and the billing address for the cardholder.  Please write this information of the back of this form.   

Or you can call and leave your credit card information at the following secured number: 714-891-2022 Ext. 13.  

Or you can fax your credit card information to 714-891-2133.

Mail To:  

 

Dr. Dodds,DVM

HEMOPET

11561 Salinaz Avenue

Garden Grove, CA 92843