Laboratory Requisition

Patient Information

Owner Name *

Patient Name *

Species *

Breed *

Date of birth *

Sex

MaleMale, NeuteredFemaleFemale, Spayed

Patient History / Lab Data

Referring Vet

Are you the referring Clinic? *

Yes No

Clinic Name *

Vet's First & Last Name *

Email *

Lab

Lab # *

Requisition Information

Chemistry

Comprehensive & plus panel (Na, K, Cl, Urea, Creatinine, T. Protein, T. Bili, ALT, AST, ALP, AST, Mg, GGT, Amylase, Lipase, Albumin, Globulin, A:G ration, Chol, Trig, Inorganic Phos, Glucose, Calcium)
Presurgical Panel (T. Protein, Urea, Glucose, ALT, ALP, Creatinine)
EPOC Blood Gas (Arterial or Venous, pH, pCO2, HCO3, TCO2, Anion Gap, Base Lactate, Na, K, Cl, iCa, Gluc, Urea, Creatinine, pO2, SO2, Hematocrit)
Liver Panel (ALT, T. Bili, ALP, GGT, Albumin, Glucose)
Kidney Panel (Urea, Creatinine, Ca, T. Prot, Albumin, Globulin, Inorganic Phos)
Individual Chemistry (Na, K, Cl, Urea, Creat, Alb, Lip, CK, Amy, ALT, AST, ALP, Ca, T. Prot, Phos, T. Bili, Chol, Trig)

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