BEECROFT OUTPATIENT LAB REQUEST FORM
Note: Results will be sent to the referring vet directly. We will not be discussing any result with the pet owners for outpatient imaging.
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PATIENT & REFERRING VET DETAILS
Submission Date
*
-
Day
-
Month
Year
Date
Name Of Referring Vet
*
Clinic Name
*
Referring Vet Contact
*
Email Address For Correspondence and Confirmation
Patient Name
*
Owner's Name
Owner's Email
Owner's Contact
*
Species/Breed
*
e.g. Feline/DSH, Bird/Cockatoo, Rodent/Chinchilla
Age
*
e.g. 3Y2M
Sex
*
Male
Female
Unknown
Neutered
*
Yes
No
Unknown
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OUTPATIENT LAB SERVICES REQUIRED
Sample submitted:
EDTA
Heparin
Serum/plain
Other
Time of Sample collection:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Sample collection required:
*
Yes
No
HAEMATOLOGY
CBC
Blood smear
BLOOD GAS
Ionised calcium
Respiratory blood gas
BIOCHEMISTRY PANELS
Chem 10
Chem 15
Chem 17
Lyte 4
SNAP TESTS
Cortisol
Giardia
CPL
Lepto
FELV/FIV
PROBNP
fPL
4DX
INDIVIDUAL SLIDES
ALB
ALKP
ALT
AMYL
AST
BUN
CA
CHOL
CK
CREA
GGT
GLU
LAC
LIPA
MG
NH3
PHOS
TBIL
TP
TRIG
Bile acids
C-Reactive protein
Fructosamine
PHBR
SDMA
T4
Other
INDEMNITY ACKNOWLEDGEMENT
By submitting this form, you acknowledge the following:
By submitting this form, you acknowledge the following:
*
The referring veterinarian acknowledges and agrees that all blood tests conducted by Beecroft do not include assessmentof the patient's medical condition or history. Referring veterinarians are to inform Beecroft if their referring patient has a history of difficulty with bloodclotting. By proceeding with the blood tests under these conditions, the referring veterinarian and client waives any liability against the healthcare providerand its affiliates for any complications or adverse outcomes resulting from the blood tests.
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