To schedule blood draw, fax form to (855) 3494 - PCL or email to [email protected] Integrative Diagnostic Services Request Form Toll Free Ph: (800) 327 – 2764 Toll Free Fax: (855) 3494 - PCL LAST PATIENT NAME FIRST M SEX FASTING M DATE OF BIRTH PATIENT S.S. # PATIENT PHONE # DRAW DATE YES F NO ORDERING PROVIDER: DRAW TIME FAX # PHONE # AM PM PATIENT ADDRESS (STREET ADDRESS, APT) CITY ADDRESS STATE ZIP MODE OF PAYMENT CASH CHECK AMOUNT CHECK # VISA PHYSICIAN SIGNATURE ORDERING PROVIDER COMMENTS MC CC HOLDER SIGNATURE AMEX CREDIT CARD # EXP DATE BILLING ADDRESS (IF DIFFERENT FROM ABOVE) SEC CODE PANELS (Please see Page 2 for Panel Description) Advanced Cardiovascular Panel $125 Chronic Inflammation Panel $575 Lundell Panel - Deluxe $295 Allergy Screening Panel $550 Comprehensive Female Hormone Panel $425 Musculo-Skeletal Panel $825 Anemia Panel $175 Comprehensive Male Hormone Panel $425 Nutritional Assessment Panel $500 Anti-Aging Panel $575 Iron Panel Thyroid Panel $125 Basic Wellness Panel $125 Lundell Panel - Basic Tick-borne Disease Panel $525 Chronic Fatigue Syndrome Panel $575 $25 $175 Individual Tests Anti-Nuclear Antibodies (ANA) $45 (SST) Free T4 $15 (SST) $75 Methyl Malonic Acid (SST) Anti-Pancreatic Islet Cell Antibodies $175 (SST) GAD 65 Antibodies (SST) $95 $25 Prostate Specific Antigen (SST) Anti-Thyroglobulin Antibodies (Anti-TG) $25 (SST) Helicobacter Pylori Abs. $85 Reverse T3 $45 T3 Total $75 (SST) (SST) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) $25 Homocysteine $85 Insulin Antibodies (SST) $25 (SST) (SST) Coenzyme Q10 (SST) (SST) $100 $45 1,25 (OH) 2 Vitamin D3 (SST) Free T3 Lyme Disease Abs. $25 (SST) (SST) Vitamin D, 25 Hydroxy $100 $30 (SST) (IgG & IgM) ***ALL ORDERS MUST INCLUDE AN ADDITIONAL COLLECTION AND HANDLING FEE OF $25*** ***Payment is expected at time of service*** SST USST SER FRZ RED LAV SLD BLU GRY GRN RYB YEL PLS URN SPUN UNSPUN SERUM TRNSPT FRZ TRNS RED LAVENDER SLIDE BLUE GREY GREEN RYL BLU ACD PLASMA URINE Advanced Cardiovascular Panel Turn Around Time 72 Hrs Anti-Aging Panel Turn Around Time 72 Hrs Chronic Inflammation Panel Turn Around Time 72 Hrs Lundell Panel - Basic Turn Around Time 72 Hrs Musculo-Skeletal Panel Turn Around Time 72 Hrs 1 SST 1 Lavender Top, 2 SSTs, 1 Sterile Urine Cup 1 Lavender Top, 3 SSTs, 1 Sterile Urine Cup 2 SSTs, 1 Red Top, 2 Lavender Tops, 1 Urine Specimen Cup, 1 Stool Cup 2 Lavender Tops, 1 Green Top, 1 Light Blue Top, 1 Urine Specimen Cup, 3 SSTs Apolipoprotein-1 (Apo A1) Apolipoprotein-B (Apo B) Apo B/A1 ratio LDL Density (Pattern) Lipoprotein a [Lp(a)] Albumin Alkaline Phosphatase (ALP) Alanine Amino Transferase (ALT) Anti-Thyroglobulin Antibodies (Anti-TG) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Albumin Alkaline Phosphatase (ALP) Alanine Amino Transferase (ALT) Anti-Nuclear Antibodies (ANA) Anti-Thyroglobulin Antibodies (Anti-TG) Alanine Amino Transferase (ALT) Albumin Alkaline Phosphatase (ALP) Aspartate Amino Transferase (AST) Bilirubin, Direct Albumin Aldolase Alkaline Phosphatase (ALP) Alpha-Antitrypsin Alanine Amino Transferase (ALT) Non-High Density Lipoprotein (HDL) Cholesterol Aspartate Amino Transferase (AST) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Bilirubin, Total Anti-Nuclear Antibodies (ANA) Remnant Lipoproteins Total High Density Lipoprotein (HDL) Total Low Density Lipoprotein (LDL) Total Very Low Density Lipoprotein (VLDL) Bilirubin, Total BUN Carbon Dioxide Complete Blood Count (CBC) with Differential Aspartate Amino Transferase (AST) Bilirubin, Total BUN Carbon Dioxide Anti ds-DNA Anti Smooth Muscle Antibodies Anti-Cyclic Citrullinated Peptide (CCP) Anti-Ribonucleoprotein Antibodies Triglycerides Chloride Complete Blood Count (CBC) with Differential Cholesterol, High Density Lipoprotein (HDL) Chloride BUN Calcium Carbon Dioxide Chloride Complete Blood Count (CBC) with Differential (Absolute) Creatine Kinase (CK) Cholesterol, Total Cholesterol, High Density Lipoprotein (HDL) Creatinine Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Creatine Kinase (CK) Creatinine Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Glucose Hemoglobin A1c Aspartate Amino Transferase (AST) Bilirubin, Total BUN C3, C4 Complement Carbon Dioxide Homocysteine Complete Blood Count (CBC) with Differential hs-C-Reactive Protein Iron Panel Lactic Dehydrogenase (LDH) Lipid Panel NRBC Occult Blood Ceruloplasmin Chloride Cholesterol, High Density Lipoprotein (HDL) Cholesterol, Total Creatine Kinase (CK) Creatine Kinase, MB Fraction (CK-MB) Allergy Screening Panel Turn Around Time 72 Hrs 10 mL Separated Serum in Plastic Vial Animal Allergen Group Cereal Allergen Group Mold Allergen Group Nut Mix Allergen Group Anti-SCL-70 Anti-Thyroglobulin Antibodies (Anti-TG) Salad Allergen Group Glucose Seafood Allergen Group Stinging Insect Allergen Group Total Immunoglobulin E (IgE) Vegetable Allergen Group Hemoglobin A1C Homocysteine hs-C-Reactive Protein Lactic Dehydrogenase (LDH) Phosphorous Potassium Cholesterol, Total Creatine Kinase (CK) Coenzyme Q10 Creatinine Epstein- Barr VCA Antibody, IgM Epstein-Barr Virus Nuclear Antigen (EBNA) Antibody, IgG Epstein-Barr Virus VCA Antibody, IgG Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Glucose Hemoglobin A1C Protein, Total Homocysteine Phosphorus Creatinine Sodium Tri-iodothyronine (T3) Uptake Tri-iodothyronine (T3), Total Thyroxine (T4), Free Thyroxine (T4), Total Thyroid Stimulating Hormone (TSH) Uric Acid hs-C-Reactive Protein Immunoglobulin A Lactic Dehydrogenase (LDH) Phosphorous Potassium Protein, Total Sodium Potassium Protein, Total Sodium Tri-iodothyroxine (T3), Free Uric Acid Urinalysis Ferritin Fibrinogen Gamma Glutamyl Transferrase (GGT) Globulin Glucose Haptoglobin Hemoglobin A1C Tri-iodothyronine (T3) Uptake Urinalysis Tri-iodothyronine (T3) Uptake Tri-iodothyronine (T3), Total Vitamin D (25-Hydroxy) Tri-iodothyronine (T3), Total Thyroxine (T4), Free Thyroxine (T4), Total Total Iron Total Iron Binding Capacity (TIBC) Thyroid Stimulating Hormone (TSH) Comprehensive Hormone Panel Thyroxine (T4), Free Thyroxine (T4), Total Transglutaminase, IgA Thyroid Stimulating Hormone (TSH) Uric Acid Anemia Panel Turn Around Time 72 Hrs 1 Lavender Top, 2 SSTs Anti-Thyroglobulin Antibodies (Anti-TG) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Complete Blood Count (CBC) with Differential Ferritin Hemoglobin Electrophoresis Reticulocyte Count Unsaturated Iron Binding Capacity (UIBC) Urinalysis % Saturation Vitamin D (25-Hydroxy) Basic Wellness Panel Turn Around Time 72 Hrs 1 Lavender Top, 2 SSTs, 1 Sterile Urine Cup Alanine Amino Transferase (ALT) Chronic Fatigue Syndrome Panel Turn Around Time 72 Hrs 1 Lavender Top, 2 SSTs, 1 Sterile Urine Cup Albumin Comprehensive Hormone Panel Turn Around Time 72 Hrs 2 SSTs Anti-Thyroglobulin Antibodies (Anti-TG) Albumin Alkaline Phosphatase (ALP) Alkaline Phosphatase (ALK) Alanine Amino Transferase (ALT) Aspartate Amino Transferase (AST) Anti-Nuclear Antibodies (ANA) Estradiol Bilirubin, Total BUN Calcium Carbon Dioxide Chloride Anti-Thyroglobulin Antibodies (Anti-TG) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Aspartate Amino Transferase (AST) Bilirubin, Total BUN Cholesterol Cholesterol, High Density Lipoprotein (HDL) Complete Blood Count (CBC) with Differential Creatine Phosphokinase (CPK), Total Creatinine Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Glucose Creatinine Hemoglobin A1C Epstein-Barr Viral Capsid Antigen (VCA) Antibody, IgM Comprehensive Wellness Panel Turn Around Time 72 Hrs 1 Lavender Top, 2 SSTs, 1 Sterile Urine Cup hs-C-Reactive Protein Epstein-Barr Virus Nuclear Antigen (EBNA) Antibody, IgG Iron, Total Lactic Dehydrogenase (LDH) Low Density Lipoprotein (LDL) Magnesium Phosphorous Potassium Protein, Total Sedimentation Rate Sodium Thyroid Stimulating Hormone (TSH) Thyroxine (T4), Free Thyroxine (T4), Total Triglycerides Tri-iodothyronine (T3) Uptake Uric Acid Urinalysis Very Low Density Lipoprotein (VLDL) Epstein-Barr Viral Capsid Antigen (VCA) Antibody, IgG Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Glucose Hemoglobin A1C Homocysteine hs-C-Reactive Protein Lactic Dehydrogenase (LDH) Phosphorous Potassium Protein, Total Rheumatoid Factor Sodium Tri-iodothyronine (T3) Uptake Tri-iodothyronine (T3), Total Thyroxine (T4), Free Thyroxine (T4), Total Thyroid Stimulating Hormone (TSH) Uric Acid Urinalysis Vitamin D (25-Hydroxy) Iron Panel - Turn Around Time 48 Hrs 1 SST Total Iron Lundell Panel - Deluxe Turn Around Time 72 Hrs 2 SSTs, 2 Red Tops, 2 Lavender Tops, 1 Blue Top, 1 Urine, 1 Stool Alanine Amino Transferase (ALT) Albumin Alkaline Phosphatase (ALK) Antinuclear Antibodies, IFA Anti-Thyroglobulin Antibodies (Anti-TG) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Aspartate Amino Transferase (AST) Bilirubin, Direct Human Leukocyte Antigen B-27 (HLA B-27) Homocysteine hs-C-Reactive Protein Immunoglobulins (IgA, IgG, IgM) Lactic Dehydrogenase (LDH) Myoglobin Phosphorous Potassium Protein, Total Rheumatoid Factor Bilirubin, Total Sjogren’s Syndrome Antibodies BUN Calcium Sodium Tri-iodothyronine (T3) Uptake Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Carbon Dioxide Tri-iodothyronine (T3), Total DHEA-S Thyroxine (T4), Free Follicle-Stimulating Hormone (FSH) Luteinizing Hormone (LH) Progesterone (Female only) Prolactin Prostate Specific Antigen (PSA) (Male only) Chloride Cholesterol, High Density Lipoprotein (HDL) Cholesterol, Total Complete Blood Count (CBC) w/Diff (Abs) C-Reactive Protein, Cardiac Creatine Kinase (CK) Creatinine Carbon Dioxide Sex Hormone Binding Globulin (SHBG) Ferritin Complete Blood Count (CBC) with Differential Chloride Cholesterol, High Density Lipoprotein (HDL) Cholesterol, Total CytomegaloVirus, IgG, IgM (CMV, IgG, IgM) Cortisol Creatine Kinase (CK) Tri-iodothyronine (T3) Uptake Tri-iodothyronine (T3), Total Thyroxine (T4), Free Thyroxine (T4), Total Testosterone, Total and Free Thyroid Stimulating Hormone (TSH) Fibrinogen Activity Free Thyroxine Index Gamma Glutamyl Transferrase (GGT) Globulin Glucose Hemoglobin A1c Homocysteine Thyroxine (T4), Total Thyroid Stimulating Hormone (TSH) Uric Acid Urinalysis Vitamin D (25-Hydroxy) Nutritional Assessment Panel - Turn Around Time 2 wks 1 Navy Blue Top Tube Amino Acids Asparagine Glutamine Serine Antioxidants Alpha Lipoic Acid Iron Coenzyme Q10 Iron Saturation Cysteine Albumin Lactic Dehydrogenase (LDH) Glutathione Tick-Borne Disease PanelTurn Around Time 96 Hrs 2 SSTs Anaplasma Phagocytophilum, IgG Antibodies Alkaline Phosphatase (ALP) Alanine Amino Transferase (ALT) Anti-Thyroglobulin Antibodies (Anti-TG) Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Aspartate Amino Transferase (AST) Bilirubin, Total BUN Carbon Dioxide Complete Blood Count (CBC) with Differential Chloride Cholesterol, High Density Lipoprotein (HDL) Cholesterol, Total Creatine Kinase (CK) Creatinine Ferritin Gamma Glutamyl Transferrase (GGT) Globulin Glucose Hemoglobin A1C Homocysteine hs-C-Reactive Protein Lactic Dehydrogenase (LDH) Phosphorous Potassium Protein, Total Sodium Tri-iodothyronine (T3) Uptake Low Density Lipoprotein (LDL) Magnesium, RBC NRBC Occult Blood Phosphorus Potassium Protein, Total RA Latex Turbid. Reverse T3 Sex Hormone Binding Globulin (SHBG) Sodium Triiodothyronine (T3) Uptake Thyroxine (T4), Direct Thyroxine (T4), Free Thyroxine (T4) , Total Total Iron Binding Capacity (TIBC) Triglycerides Tri-iodothyronine (T3), Total Tri-iodothyronine (T3), Free Thyroid Stimulating Hormone (TSH) Uric Acid Urinalysis Vitamin D, 25-Hydroxy Very Low Density Lipoprotein (VLDL) Thyroid Panel - Turn Around Time 48 Hrs 1 SST Anti-Thyroglobulin Antibodies (Anti-TG) Total Iron Binding Capacity (TIBC) Babesia Microti, IgG Antibodies Tri-iodothyronine (T3), Total Anti-Thyroid Peroxidase Antibodies (Anti-TPO) Vitamin B12 Unsaturated Iron Binding Capacity (UIBC) % Saturation Ehrlichia Chaffeensis IgG Antibodies Lyme Disease IgG Antibodies Lyme Disease IgM Antibodies Thyroxine (T4), Free Thyroxine (T4), Total Thyroid Stimulating Hormone (TSH) Uric Acid Urinalysis Vitamin D (25-Hydroxy) Tri-iodothyronine (T3) Uptake Tri-iodothyronine (T3), Total Thyroxine (T4), Free Thyroxine (T4), Total Thyroid Stimulating Hormone (TSH) Vitamin C Vitamin D Vitamin K Biotin Folate Pantothenate Selenium Vitamin E Carbohydrate Metabolism Chromium Fructose Sensitivity Glucose-Insulin Metabolism Fatty Acids Oleic Acid Immunidex Immune Response Score Metabolites Choline Carnitine Inositol Minerals Calcium Copper Magnesium Manganese Zinc Spectrox for Total Antioxidant Function ™ Vitamins Vitamin A Vitamin B1 Vitamin B2 Vitamin B3 Vitamin B6
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