Test Request Submission Form/consultation Form - Hemopet/hemolife
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2T E S T R E Q U E S T / C O N S U L T A T I O N
F O R M
EFFECTIVE 02/2016
HEMOPET / HEMOLIFE – W. JEAN DODDS, DVM
11561 SALINAZ AVENUE, GARDEN GROVE, CA 92843
PHONE: 714-891-2022
FAX: 714-891-2123
BILLING: 714-891-2022 EXT 113
VETERINARIAN NAME:
DATE:
(Name MUST be provided)
CLINIC NAME:
Address:
City:
State:
Zip:
Phone:
FAX:
Email:
CLIENT NAME:
Address:
City:
State:
Zip:
Phone:
FAX:
Email:
PET NAME:
Species (circle):
Canine
Feline
Equine
Other
Breed:
Age:
Sex (circle):
F
FS
M
MN
Weight:
YES
NO
If Yes, brief list:
ON MEDICATION (circle):
MUCH?
_____________
HOW OFTEN? _____________
BLOOD DRAWN _____HRS POST PILL
HOW
REASON FOR TESTING & BRIEF HISTORY:
HISTORY OF FOOD INTOLERANCE ?
FOR HOW LONG ?
DIET INFORMATION:
HOW LONG ON CURRENT DIET:
___ Thyroid Profile 5™ PLUS ( T4, free T4, T3, free T3, TgAA – PLUS CBC, Differential , Chemistries)
$175.00
___ Thyroid Profile 5™ ( T4, free T4, T3, free T3, TgAA )
$ 102.00
___ Thyroid GOLD™ Registration & Certificate ONLY
(
Order with ANY Thyroid Profile 5™
)
Will ONLY be issued with a normal / passing Thyroid Profile 5™. Identifies dogs that are phenotypically “thyroid normal” for breeding programs.
$ 15.00
Registered Name and # must be provided. A hard copy of the certificate will be mailed to address written in client section above.
Registered Name_____________________________________Register # _________________D.O.B_________________
$ 160.00
___ Thyroid Profile 4 PLUS ( T4, free T4, T3, free T3 – PLUS CBC, Differential , Chemistries )
___ Thyroid Profile 4 ( T4, free T4, T3, free T3 )
$ 92.00
$ 82.00
___ Thyroid Profile 2 ( T4, free T4)
___ OFA Thyroid Registry, Expanded Profile(T4, T3, free T3, T4AA, T3AA, FT4ED, cTSH, TgAA) Separate OFA form & check
$ 145.00
for $15 made out to “OFA” required.
+ $ 15.00
___ CBC, Differential, Chemistries
$ 82.00
___ Distemper & Parvo Vaccine Titers
$ 52.00
Separate FAVN form required)
$ 98.00
___ Rabies Titer
(FAVN Testing is $120.00,
___ Heartworm Antigen
$20.00
___ Consultation Request Only
$ 150.00
(Antigens/Foods being tested are beef, corn, duck,
___ Nutriscan ® Diagnostics (Food Intolerance Testing) 24 foods;
$ 298.00
wheat, soy, cow’s milk, lamb, venison, chicken, turkey, pork, white fish, hen’s egg, barley, lentils, millet, oatmeal,
salmon, rabbit, rice, quinoa, potato, sweet potato, and peanut).
___ Other Tests
$ ______
Additional amount as a Donation to HEMOPET
$ ______
TOTAL
$ ______
Credit Card Account Number:
Type:
Exp Date:
CVC:
Authorized Signature:
PRINT NAME as it appears on your card:
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