SMALL ANIMAL REQUEST FORM - IDEXX

1 PLEASE TICK IF YOU WISH FOR THE SCREEN TO BE NON INTERPRETED^CHEMISTRY ABABile Acid - FastingABASBile Acid Stimulation TestABNP/FCardiopet proBNPABLITT otal BilirubinACPLSpec cPL AFOLCBF olate and CobalaminAFRUF ructosamineAGGTGGTAPCRP rotein : Creatinine RatioASDMASDMAASPEP rotein Electrophoresis (Serum)ATLIC/ATLIFTLIAUCEU rine Chemistry, Microscopy & Culture, Protein : Crea RatioBAPBile Acid Post Feed ENDOCRINOLOGY ACORTC ortisolAT4 Total T4 AVT4 Free T4 by immunoassayTSHAC anine TSHAFT4 Free T4 CANINE SPECIFIC ACRPC Reactive ProteinALEIL eishmania serology FELINE SPECIFIC AFFFeLV/FIVAMPCH aemoplasma RealPCRTM HEAMATOLOGY ACC/AFCC oombs (Canine/Feline)ACOAC oagulation ScreenAFBCC omprehensive HaematologyAFILMFilm MorphologyIDEXX Reference LaboratoriesSMALL ANIMAL REQUEST FORM 2024 IDEXX Laboratories, Inc.

2 All rights reserved. 2012019-0124-UKCHEMISTRY BASBile Acid Stimulation TestCBNP/FCardiopet proBNP ( )CPLI / FPLISpec cPL (Canine) / Spec fPL (Feline)CTNI/FTNIC ardiopet proBNP and Troponin I HSFRUF ructosaminePCRUP rotein : Creatinine Ratio (Urine) SDMASDMASPEP rotein Electrophoresis (SERUM)TFCB/ FTFCTLI, Folate & Cobalamin (Canine/Feline) TLIC/TLIFTLI (Canine/Feline)ENDOCRINOLOGYTHYROID CTPV/FTPVT hyroid PanelCTSHC anine TSH and Total T4FT4 EDFree T4T4 MTotal T4 TSHSC anine TSHVFT4 Free T4 by immunoassayADRENAL/PITUITARY ACTHC anine ACTH Stimulation 2 SamplesACTVACTH Stimulation (Vetoryl)CORTPPC ortisol (Pre Trilostane Pill)DEXLD examethasone Suppression (Low)DEXHD examethasone Suppression (High)EACTHE ndogenous ACTHFACTF eline ACTH Stimulation 3 SamplesUCCRU rine Cortisol.

3 Creatinine RatioCANINE SPECIFICCRPRC Reactive ProteinFELINE SPECIFICSAAS erum Amyloid A SCREENS ADD ON STANDALONE TESTSHAEMATOLOGYANFA ntinuclear AntibodiesCC/FCCoombs COAGB asic Coagulation ScreenDICPDIC ScreenFBCSIDEXX CBC SelectFILMB lood Film ExaminationTHERAPEUTIC MONITORING DIGD igoxinKBRP otassium BromideLEVL evetiracetamURINE SCREENS Please indicate collection method: o Cystocentesis o Catheter o Free CatchUCEB asic Urine ScreenUCEPE xtended Basic Urine ScreenUCECC omprehensive Urine ScreenUCECPP remium Urine ScreenREPRODUCTION AMHAnti-Mullerian Hormone (Canine/Feline/Equine)PGTP rogesterone (Canine/Feline/Equine)PGT+ AMHP rogesterone and Anti-Mullerian HormoneINFECTIOUS DISEASE ANGIOA ngio Detect TestLEIL eishmania serology FFFeLV and FIVTOXOT oxoplasma IgG/IgMMPCRH aemoplasma RealPCRPREVIOUS REF.

4 N FOUNDATIONALChem 10 Chem 10 CLIPChem 15 Chem 15 CLIPChem 17 Chem 17 CLIPLYTE4 LYTE4 CLIPNSAIDNSAID CLIPPLEASE TICK IF YOU WISH FOR THESCREEN TO BE INTERPRETEDI ntermediate Screen with Urine INTUN CORE PROFILES SP1 IBasic SP1N SP2 IStandard SP2N SP3 IExtended SP3N PROBLEM SPECIFIC GER1 IPolyuria/Polydipsia GER1N GERTIG eriatric GERTN KPIK idney Disease Monitoring KPN SP4 IFits and Faints SP4N SLFTIL iver Monitoring SLFTN CANINE SPECIFIC CARDIC ardiac CARDN CASC anine Anaemia Profile CPUOIC anine Pyrexia of Unknown Origin Profile DIARCIC anine Diarrhoea DIARCN PANCIV omiting/Pancreatitis PANCN DIGMD igoxin Profile FELINE SPECIFIC CARFIF eline Cardiac CARFN DIARFIF eline Diarrhoea DIARFN FASF eline Anaemia Profile PANFIU nder The Weather(incl.)

5 Spec fPL ) PANFN DIGMFD igoxin Profile MONITORING INTERPRETED DIABID iabetes Monitoring FTHYIF eline Thyroid Monitoring Profile LEIMCIL eishmania Monitoring Profile PPLFTP henobarbital & Potassium Bromide Profile PLFTP henobarbital Profile T36 XTrilostane (vetoryl) Monito-ring Profile - Prepill Cortisol T36 PTrilostane (vetoryl) Monitoring Profile - ACTH Stimulation TestANIMAL ID / PIMS NUMBER OWNER S NAMENAME OF ANIMALSPECIESAGEBREEDSEXNEUTERED ENTIRELAB NUMBER (LAB USE ONLY)VET CODEDATEVETERINARY SURGEONADDRESS STAMPIn order to enable us to process your sample(s) efficiently, please complete all information on this form using black inkFor a full list of all available test, sample requirements and online ordering please visit Laboratories Ltd Tel: UK: +44 (0) 2037887508 Eire: +353 (0) 15621211 Fax: 01937 544001 DISCOUNT IDEXX Advantage Programme Code: IDAV Please tick box for IDEXX Advantage discount and ensure you enclose your IDEXX Analyser result or SNAP Test device.

6 Advantage prices will only be applied if IDEXX In Clinic results / SNAP device are received. Tests only applicable if marked with MANDATORY INFODoes the ANIMAL originate from a country outside the UK (please state country)Y oN o Has the ANIMAL recently travelled abroad or been in contact with a non-UK bred ANIMAL that has travelled abroadY oN oPlease indicate if the sample has been obtained from a patient receiving chemotherapy or radioactive iodineY oN oWhere: (Cannot be used in conjunction with Foundational)^FOR LAB USE ONLYEDTASEP SERUMUN SPUN GELHEPARINPLAIN URINEUNLABELLEDREVSMEARWHOLE BLOODPART SPUN GELHEPARIN PLASMABORIC URINELOCK BOXNHISEDTA PLASMAFLUORIDESPUN GELCITRATECOURIERA nalyser result/SNAP TEST enclosedCITRATE PLASMAGTDIDEXX handles personal data responsibly and has adopted the privacy policy which can be found at provide history to allow for interpretation of Interpreted Profiles (please indicate Differential Diagnosis / Disease Suspected / Specific questions you would like answered)

7 O Fasting Sample o Non Fasting Sample o Please indicate if the sample has been obtained from a patient receiving chemotherapy or radioactive iodineo Does the ANIMAL originate from a country outside the UK (please state country) o Has the ANIMAL recently travelled abroad or been in contact with a non-UK bred ANIMAL that has travelled abroadOTHER ASSAYS REQUIRED Please check Quick Guide or Directory of Products and Services for further assays and specify.