Patient Intake Form: #6

Thomas Abshier, ND
Phone: 503 255 9500, Fax: 503 255 1888, Pager: 503 599 4492, email: naturedox@qwest.net

This form can be copied into Word (edit, select all, copy, paste) and printed
Call the lab and get the lab name, address, phone, & fax number.
Call/fax/email me and tell me the lab's phone/fax number:
I will call/fax a confirmation to the lab to authorize the lab requisition.
Make sure that you bring any tests kits with you that may require a blood draw.
Make sure you have called DHL/Fed Ex/UPS for a pickup time if there is a draw for next day deliver at another lab.
Call Lab and make an appointment.
If there is any problem at the lab, call me at 503 255 9500, or page me at 503 599 4492
In general: fast after dinner, and go in for blood draw in the AM.

Note: the following tests indicated by "***" next to the test name, or the group, indicates a test/group that is typically ordered

Note: Test costs are those charged by the Portland Naturopathic Clinic (503 552 1551). 
These prices are given for comparison only, and are subject to change.
Call the lab of your choice to check prices before making an appointment.
Lab costs will probably not be covered by insurance.

Perform tests for -- Patient Name:
Date of Birth: 
ICD9: Diagnosis Code(s): Health Screen

Venipuncture/Blood draw: $15.00 (may be more for multiple draws)
Lab Handling Fee: $10.00 (dependent on number of tests, etc.) 

Chemistry Screen: $39.00 ***

Calcium
Sodium
Chloride
Potassium
CO2
BUN
Creatinine
Glucose
Anion Gap

Miscellaneous Tests:

Uric Acid $6.00 ***
Phosphorus $12.00 ***
Magnesium, RBC
ESR - Sedimentation Rate $ 12.00 ***

Liver panel: $39.00 ***

Alkaline Phosphatase
AST/SGOT
ALT/SGPT
GGT
LDH - Lactose Dehydrogenase
Total biliribin
Direct bilirubin if Total bilirubin = >1.3
Total protein
Globulin total
Albumin

Lipids: $39.00 ***

Total cholesterol
LDL
HDL
Triglycerides

Heart Risk Panel: $149.00 (Genova Diagnostics)

Cardio CRP (C Reactive Protein) $45
Homocysteine
Fibrinogen
Lipoprotein (a), Apolipoprotein A1, B, lipid panel

Anemia Panel: $48.00

Iron - serum
TIBC - Total Iron Binding Content
% Saturation
Ferritin

Hemoglobin A1C: $30.00
Insulin: $60.00
GITT (Glucose Insulin Tolerance test: 3 hour) $104.00

Hand Differential: $15

(Automated % differential and Absolute numbers):$26
WBC - White Blood Cells, Lymphocytes, Monocytes, Eosinophils, Basophils, Neutrophils, Bands, RBC - Red Blood Cells, Hgb - Hemoglobin, Hct - Hematocrit, MCV - Mean Cell Volume, MCH, MCHC, Platelets, MPV - Mean Platlet volume

Thyroid Panel:

T4 total $35.00 ***
Free T4 $35.00
TSH $35.00

(NCNM Thyroid panel: TSH, Free T4, & Free T3) $75.00

Free T3 $30.00
Reverse T3 $30.00
Anti Thyroglobulin $30.00
Anti Thyroid Peroxidase $30.00

(Genova Panel: All of regular & extended) $149.00

Estradiol $95.00
Progesterone $80.00
Free Testosterone $85.00
Total Testosterone $85.00

DHEA Sulfate (serum): $70.00
Cortisol AM (serum):

Lymphocyte subset panel: $340.00

(Red Labs, blood draw, kit to take to lab)
CD 3 All T cells, CD 4 Helper cells, CD 8 Suppressor cells, CD 19 B Cells, NK cells (CD 56/57)

INR
Prothrombin Time

Adrenal stress Index: $99.00

(Diagnos-Tecs, saliva test, kit, self-send)
Cortisol, 4 samples over full day
DHEA (from average of samples)

Diagnos-Tecs, saliva and stool, kit, self-send: $149.00
Bacteria, Fungi, Parasites, enzymes, Gluten, food antibodies, SIGA, inflammation

CDSA - Genova $199.00 (Comprehensive Digestive Stool Analysis)

Steroid Panel: $250.00

(Rhein Consulting Labs: 24 hour urine collection, self-send)
Full spectrum average of steroid hormones over 24 hour period.
Adrenal hormones (Cortisol and metabolites)
Sex Hormones and metabolites (Testosterone, Estrogen, Progesterone)

MRT: $350.00 (blood draw, kit, 150 foods, WBC reactivity to food)

ALCAT: $320.00 (blood draw, kit, 150 foods, WBC rxn to food)

US BioTek: $185.00 (blood draw, 96 foods, Antibodies to food)

US BioTek: $135.00 (finger prick, kit, 96 foods, Antibodies to food)

Urinary Neurotransmitter Test: $113.00

Neuroscience, morning collection of urine
Epinephrine, Norepinephrine, Dopamine, Serotonin, GABA Phenylethylalanine

Urine Toxic Metal Assay: $58.00

Genova Labs; collection kit, 16 hour challenge;
plus challenge/chelating agent: Zeolite $40)

Chronic Fatigue Assay: $1000.00 +/-

(Reb Labs Inc., Blood draw, kit to take to lab)
Assay of viruses and blood enzymes related to viral infection correlated to Chronic Fatigue Syndrome

Urine Organic Assay: $250.00

(US BioTech, kit, 24 hr urine collection, metabolites from cellular metabolism indicative of vitamins, minerals, toxins, fungus, amino acid levels)

Amino Acid Assay:

(US Biotek, kit, finger prick) $99.00

US Biotek, blood draw: $200
40 amino acids

Candida Antibodies and Antigen Complex: $70

(Antibody Assay Labs, blood draw)