Patient Directed Laboratory Orders

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Date

BENE BEYOND FAMILY MEDICINE PLLC
1702 1st Street East
STE G18
HUMBLE, TX 77338

P) 855-236-3492
F) 815-371-1232

Referring Physician:
ALSOBROOKS, CURRISSA MD NPI: 1598050148

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Select ONE of the following lab panels:

Vitamin Panel - Comprehensive - Lab orders and report only (lab tests not included in price)

Multiple vitamins including A, B, C, D and E as well as minerals and electrolytes such as iron and magnesium.

$100.00 Quantity

Vitamin Panel - Extensive - Lab orders and report only (lab tests not included in price)

All of the vitamins, electrolytes and minerals included in the comprehensive vitamin panel PLUS more B vitamins, vitamin K, chromium, copper, selenium and zinc.

$125.00 Quantity

Fatigue Panel - Lab orders and report only (lab tests not included in price)

This work up includes the blood count, blood sugar, liver and kidney function, thyroid function, B vitamins, vitamin D and iron.

$95.00 Quantity

Bariatric Surgery Panel - Lab orders and report only (lab tests not included in price)

This panel includes multiple vitamins and minerals that may be affected by bariatric surgery as well as a complete blood count, blood sugar, liver and kidney function and thyroid function.

$110.00 Quantity

Weight Assessment Panel - Lab orders and report only (lab tests not included in price)

This panel includes assessment of thyroid function, blood sugar levels, vitamins B and D as well as liver and kidney function.

$95.00 Quantity

Hair Loss Panel - Lab orders and report only (lab tests not included in price)

This panel evaluates blood count, iron levels, thyroid function studies, liver function, kidney function, vitamins and minerals.

$95.00 Quantity

Total

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Please select all condition / symptoms that apply:

ICD Diagnosis Code(s):

TESTS

Vitamin Panel 1

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84590     Vitamin A&#13;&#10;84207    Vitamin B6&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;82180     Vitamin C&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;84446     Vitamin E&#13;&#10;83540     Iron&#13;&#10;82728     Ferritin&#13;&#10;83550     Total Iron Binding Capacity&#13;&#10;83735     Magnesium, RBC

Vitamin Panel 2

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84590     Vitamin A&#13;&#10;84425     Vitamin B1&#13;&#10;84252     Vitamin B2&#13;&#10;84591     Vitamin B3&#13;&#10;84591     Vitamin B5&#13;&#10;84207    Vitamin B6&#13;&#10;84591     Vitamin B7&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;82180     Vitamin C&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;84446     Vitamin E&#13;&#10;84597     Vitamin K&#13;&#10;82495     Chromium, Blood&#13;&#10;82525     Copper, Plasma&#13;&#10;83540     Iron&#13;&#10;83735     Magnesium, RBC&#13;&#10;84255     Selenium, Blood&#13;&#10;84630     Zinc, RBC&#13;&#10;

Bariatric Profile

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84439     TSH&#13;&#10;84443     T4, Free&#13;&#10;83036     A1c&#13;&#10;83525     Insulin&#13;&#10;84590     Vitamin A&#13;&#10;84425     Vitamin B1&#13;&#10;84252     Vitamin B2&#13;&#10;84207    Vitamin B6&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;84446     Vitamin E&#13;&#10;84597     Vitamin K&#13;&#10;83540     Iron&#13;&#10;83735     Magnesium, RBC&#13;&#10;84630     Zinc, RBC&#13;&#10;

Fatigue Workup Female

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84439     TSH&#13;&#10;84443     T4, Free&#13;&#10;83036     A1c&#13;&#10;83525     Insulin&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;83540     Iron

Fatigue Workup Male

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84439     TSH&#13;&#10;84443     T4, Free&#13;&#10;83036     A1c&#13;&#10;83525     Insulin&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;83540     Iron&#13;&#10;84403     Testosterone, Total&#13;&#10;84402     Testosterone, Free&#13;&#10;

Weight Panel

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84439     TSH&#13;&#10;84443     T4, Free&#13;&#10;83036     A1c&#13;&#10;83525     Insulin&#13;&#10;82306    Vitamin D 25-OH&#13;&#10;

Hair Loss Profile

85025     CBC&#13;&#10;80053     CMP&#13;&#10;84439     TSH&#13;&#10;84443     T4, Free&#13;&#10;83036     A1c&#13;&#10;83525     Insulin&#13;&#10;82746     Folic Acid&#13;&#10;82607     Vitamin B12&#13;&#10;83540     Iron&#13;&#10;84630     Zinc, RBC&#13;&#10;82642     Dihydrotestosterone

INSTRUCTIONS:

Overnight fasting (or at least 6-8 hours fasting if not at night) is required.&#13;&#10;Refrain from taking vitamins or mineral supplements 3 days before specimen collection and from eating legumes and leafy vegetables 2 days before specimen collection for more accurate results.

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Select ONE of the following lab panels:*

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