Dr. Dodds' Information Form

Veterinarian:	Clinic:
Veterinarian's Address:
Veterinarian's Phone:	Veterinarian's Fax:
Client:
Client's Address:
Client Phone:	Client fax # for a copy of the report :
Pet Name:	Breed:	Age:
Species: Canine Feline Equine Other	Sex (circle): F FS M MN	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 D8T (T3 and T4, Free T3 and T4, T3 and T4 auto antibodies). **IMPORTANT* If on thyroid meds draw blood 4 - 6 hours after med and note dosage and hours here ===> DOSE: ______mg; HOURS: ______	$65.00
	Urine Bile Acid Test #85645	$45.00
	Blood Serum Bile Acid Tests #T220 - Pre and post eating	$47.00
	Phenobarbital Profile #5624 **IMPORTANT* Number of hours between giving Phenobarbital and blood draw _______	$47.00
	Potassium Bromide Profile #16120	$56.00
	Profile #7200 includes CBC, Differential, Superchem (includes liver enzymes) and D8T thyroid. (If no CBC or Dif, deduct $6.00) **IMPORTANT* Number of hours between thyroid medication and blood draw_________	$95.00
	CBC, Differential & Superchem (includes Liver Enzymes) # SA020	$55.00
	SuperChem only (no CBC or Dif.) # SA010	$49.00
	Dr. Dodd's Consultation Request Only. (Attach All Lab or Medical Information). Deductible Donation to Non-Profit HEMOPET ====>	$30.00
	Other Tests (please list)	$
	Total:	$