Hemopet

The Hemopet/Hemolife Test Request Form and Instructions can now be filled out online using the blank form shown below. You can send the samples by courier (FedEx) or alternative delivery through the Postal Service or other courier such as UPS. For International Samples, including Canada and Mexico, see special shipping instructions. US Customs clearance requires a letter specifying that the "sample is from a dog or cat for diagnostic purposes only, and is non-infectious."

Veterinarian	First Name Last Name
Clinic Name
Address		Email		Confirm Email
			send report to this Email-address
City		State		Zip
Phone		Fax		Cell

Owner	First Name Last Name
Address		Email		Confirm Email
			send report to this Email-address
City		State		Zip
Phone		Fax		Mobile

Pet Name		Species		Breed
Pet Age	Yrs Months	Sex		Weight	Lbs
Pet Diet		Medication

	Reason for testing & brief history (short sentence):
Thyroid Medication	check here if on Thyroid Medication.
List all Medication		How much?		How often?
Blood drawn	hrs since last pill

Click the submit button below to submit & print your request and generate your tracking number.

Check tests desired		Cost
	Thyroid Profile 5™ PLUS WHOLE BLOOD & SERUM NEEDED (T4, free T4, T3, free T3, TgAA - PLUS CBC, Differential, Chemistries, SDMA) Shipping: Send 1 mL WHOLE BLOOD in lavender-top tube (EDTA) AND 1.5 mL SERUM. Transfer SERUM to empty redtop or plastic tube. With whole blood tube, include ice pack when shipping, but do not freeze sample. Should be sent with overnight or 2-day courier. *Test includes CBC with differential, Chemistry Panel and Thyroid 5 Profile.*	$ 225.00
	Thyroid Profile 5™ (T4, free T4, T3, free T3, TgAA) For patient on thyroid medication, please draw blood 4-6 hours after giving thyroid medication, if applicable. Collect 3 to 5 mL of blood in a red top tube (RTT). Centrifuge. Transfer SERUM to empty redtop or plastic tube. 1.0 mL SERUM is REQUIRED for the Thyroid Profile 5. Shipping (Within U.S.): USPS priority 2-day or even regular 1st mail. Put the serum tubes in a zip lock baggie & then wrap with bubble wrap or padded paper and put in a small sturdy box with the filled out Test Request Form. NO ICE PACK IS REQUIRED. Serum samples are viable for about 14 days at room temp (except in extremely hot weather conditions). Intl. Shipping: See "Forms" tab on website for instructions.	$ 125.00
	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 A hard copy of the certificate will be mailed to the address written in client informational section. Please provide Date of Birth and pet registration number for certificate.	$ 15.00
	Thyroid Profile 4 PLUS WHOLE BLOOD & SERUM NEEDED (T4, Free T4, T3, Free T3 - PLUS CBC, Differential , Chemistries, SDMA) Formerly the D1 Shipping: Send 1 mL WHOLE BLOOD in lavender-top tube (EDTA) AND 1.5 mL SERUM. Transfer SERUM to empty redtop or plastic tube. With whole blood tube, include ice pack when shipping, but do not freeze sample. Should be sent with overnight or 2-day courier. *Test includes CBC with differential, Chemistry Panel and Thyroid 4 Profile.*	$ 205.00
	Thyroid Profile 4 (T4, free T4, T3, free T3) For patient on thyroid medication, please draw blood 4-6 hours after giving thyroid medication, if applicable. Collect 3 to 5 mL of blood in a red top tube (RTT). Centrifuge. Transfer SERUM to empty redtop or plastic tube. 1.0 mL SERUM is REQUIRED for the Thyroid Profile 4. Shipping (Within U.S.): USPS priority 2-day or even regular 1st mail. Put the serum tubes in a zip lock baggie & then wrap with bubble wrap or padded paper and put in a small sturdy box with the filled out Test Request Form. NO ICE PACK IS REQUIRED. Serum samples are viable for about 14 days at room temp (except in extremely hot weather conditions). Intl. Shipping: See "Forms" tab on website for instructions.	$ 115.00
	Thyroid Profile 2 (T4, Free T4) For patient on thyroid medication, please draw blood 4-6 hours after giving thyroid medication, if applicable. Collect 3 to 5 mL of blood in a red top tube (RTT). Centrifuge. Transfer SERUM to empty redtop or plastic tube. 0.5 mL SERUM is REQUIRED for the Thyroid Profile 2. Shipping (Within U.S.): USPS priority 2-day or even regular 1st mail. Put the serum tubes in a zip lock baggie & then wrap with bubble wrap or padded paper and put in a small sturdy box with the filled out Test Request Form. NO ICE PACK IS REQUIRED. Serum samples are viable for about 14 days at room temp (except in extremely hot weather conditions). Intl. Shipping: See "Forms" tab on website for instructions.	$ 105.00
	OFA Thyroid Registry (free T4 ED, TSH, TgAA) ($185 test + separate $15 check) 1.5 mL SERUM is REQUIRED to complete all testing. Include completed & signed OFA form, and a separate check for $15.00 made out to OFA. Collect 3 to 5 mL of blood in a red top tube (RTT). Centrifuge. Transfer SERUM to empty redtop or plastic tube. Shipping (Within U.S.): USPS priority 2-day or even regular 1st mail. Put the serum tubes in a zip lock baggie & then wrap with bubble wrap or padded paper and put in a small sturdy box with the filled out Test Request Form. NO ICE PACK IS REQUIRED. Serum samples are viable for about 14 days at room temp (except in extremely hot weather conditions). Intl. Shipping: See "Forms" tab on website for instructions.	$ 185.00
	CBC, Differential, Chemistries, SDMA WHOLE BLOOD & SERUM NEEDED Send 1 mL WHOLE BLOOD in lavender-top tube (EDTA) AND 1.5 mL SERUM. Transfer SERUM to empty redtop or plastic tube. With whole blood tube, include ice pack when shipping, but do not freeze sample. Should be sent with overnight or 2-day courier. *Test includes CBC with differential and Chemistry panel.*	$ 135.00
	Heartworm Antigen Send 0.5 mL SERUM	$ 25.00
	Distemper & Parvo Vaccine Titers Send 0.5 mL SERUM Shipping (Within U.S.): USPS priority 2-day or even regular 1st mail. Put the serum tubes in a zip lock baggie & then wrap with bubble wrap or padded paper and put in a small sturdy box with the filled out Test Request Form. NO ICE PACK IS REQUIRED. Serum samples are viable for about 14 days at room temp (except in extremely hot weather conditions). Intl. Shipping: See "Forms" tab on website for instructions.	$ 75.00
	Rabies Titer RFFIT (Not for travel) Measures response to rabies vaccinations. Send 1.0 mL SERUM in red top or plastic tube. Note: Allow 21-28 days testing time.	$ 175.00
	FAVN - Rabies (for pet travel to Rabies free countries or regions) Please include separate FAVN form with sample. Send 1.0 mL SERUM in red top or plastic tube. Note: Allow 21-28 days testing time.	$ 225.00
	von Willebrand Test Plasma from citrate tube (Blue top) needed. Take 1 mL PLASMA from a citrate tube (Blue Top Tube). Transfer plasma to empty redtop or plastic tube. Include ice pack when shipping- OK to freeze. Should be sent with overnight or 2-day courier. Clearly label the tube as "PLASMA." Note: Allow 4-7 days testing time.	$ 110.00
	Phenobarbital DO NOT USE A SERUM SEPARATOR TUBE WITH GEL BARRIER Blood sample should be drawn 4-6 hours after giving medication. 1.0 mL SERUM is required. Draw in RTT. DO NOT USE A SERUM SEPARATOR TUBE WITH GEL BARRIER Transfer SERUM to empty redtop or plastic tube.	$ 99.00
	Bromide DO NOT USE A SERUM SEPARATOR TUBE WITH GEL BARRIER Blood sample should be drawn 4-6 hours after giving medication. 1.0 mL SERUM is required. Draw in RTT. DO NOT USE A SERUM SEPARATOR TUBE WITH GEL BARRIER Transfer SERUM to empty redtop or plastic tube.	$ 120.00
	ADD ON TSH	$ 50.00
	ADD ON TGAA	$ 50.00
	Consultation Request Only Please visit our Online Consultation request form page here: Online Consultation request form.	$ 200.00
	CellBIO (Isoprostane) Includes kit with saliva collection instructions at no charge. detection of cellular stress PLEASE NOTE: International Shipping is $35	$ 150.00
	NutriScan (24 foods) Includes kit w/ saliva collection instructions at no additional charge SALIVARY IgA & IgM (Expect results within 2-3 weeks) Your pet will need to fast overnight before testing; water is okay. (Antigens/Foods being tested are beef, corn, duck, lentil, wheat, soy, cow's milk, lamb, venison, chicken, turkey, and white fish, hen's egg, barley, millet, rice, oatmeal, salmon, rabbit, quinoa, potato, peanut, pork, and sweet potato) Please note: pets SHOULD NOT take Apoquel® by Zoetis for at least 2 weeks before performing Nutriscan testing, as it can suppress bowel surface immune reactions. PLEASE NOTE: international shipping is $35	$ 298.00
	Equine NutriScan(22 foods) Includes kit with saliva collection instructions at no additional charge. SALIVARY IgA & IgM (Expect results within 2-3 weeks) Your pet will need to fast overnight before testing; water is okay. (Antigens/Foods being tested are Alfalfa, Apple, Barley, Bermuda Grass, Brome Grass, Carrot, Corn, Cottonseed, Fescue Grass, Flax Seed, Kentucky Blue Grass, Meadow Foxtail, Molasses, Oat, Orchard Grass, Red Clover, Rice, Rye, Rye Grass, Sugar Beet, Timothy Grass, and Wheat)	$ 398.00
	NutriScan (24 foods) + CellBIO (Isoprostane) Combo Includes kit with saliva collection instructions SALIVARY IgA & IgM and detection of cellular stress (Expect results within 2-3 weeks) Your pet will need to fast overnight before testing; water is okay. (Antigens/Foods being tested are beef, corn, duck, lentil, wheat, soy, cow's milk, lamb, venison, chicken, turkey, and white fish, hen's egg, barley, millet, rice, oatmeal, salmon, rabbit, quinoa, potato, peanut, pork, and sweet potato) Please note: pets SHOULD NOT take Apoquel® by Zoetis for at least 2 weeks before performing Nutriscan testing, as it can suppress bowel surface immune reactions. PLEASE NOTE: International Shipping is $35	$ 400.00
	International Orders (Nutriscan and CellBIO) Please check for International Orders (Ships Fed Ex)	$ 35.00
ADDITIONAL DONATION TO HEMOPET		$
TOTAL		$ 0.00

Optional: If at any time you would like an additional Nutriscan consultation about your results for $35, please send us an Online Consultation Request.

NUTRISCAN: Return mailing to Hemopet needs to be in a protected package or envelope. No refrigeration is necessary, and the saliva sample is viable for up to 30 days; however we do recommend that the sample should arrive at Hemopet within 10 days of being taken.

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Payment methods accepted: check, creditcard or moneyorder. Please make check or moneyorder out to "Hemopet" and include in package along with sample(s) when sending.
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