NEW BOLTON CENTER

Referring Vet/Practice NEW BOLTON CENTER
Clinical Pathology Test Request Form
Owner’s name
TENTATIVE DIAGNOSIS
Animal location (state)
Animal’s name TIME OF SAMPLE COLLECTION
Species Breed Age Sex AM/PM
√ Hematology
CBC (L) 300 Outside Vet 301
ICO (instrument count only) (L) 533
PCV (L) 313
TP (L) 319
Fibrinogen (B) 304 mg/dL
Platelet count (L) 315 Na-Citrate (B)
x10 3 /ul
Reticulocyte count (L) 317
% x10 6 /ul
Slide evaluation (L) 540
√ Chemistry/Immunology
Equine profile (G) 519 Na, K, Cl, CO2, Creat,
Ca, Phos, Gluc, TP, Alb, Tbili, AST, CK, GGT
Bovine profile (G) 338 Na, K, Cl, CO2, Creat,
BUN, Ca, Mg, Phos, Gluc, Alb, TP, AST, CK,
GGT, Cholesterol
Liver profile (G,R) 531 SDH (R) requires
submission ≤3 hours post-collection
Alb, SDH, Tbili, Dbili, GGT, Chol, Triglycerides
Renal profile (G) 532 Creat, Phos, Na, K, Cl,
Ca, TCO2
Flex-Pick 4 panel (G) 534
ACTH (L) 539
Cortisol (R) 590
Dexameth suppression, 2 cortisols (R) 595
Insulin (R) 591
T3 (R) 588
T4 (R) 589
Pituitary PI Dysfunction profile (L,R) 542 Preand
post ACTH, insulins
√ Urine Chemistry
Sodium 378 mmol/L
Potassium 380 mmol/L
Chloride 383 mmol/L
Creatinine 385 mg/dL
GGT 391 U/L
Date/Time
√ Individual Tests √
Technician
Urinalysis
Glucose (G) 435 Complete UA 370
BUN (G) 423
SDH (R) 480
Collection method:
AST (G) 460 Specific gravity
GGT (G) 469 pH Color
Total bilirubin (G) 419 Protein
Direct bilirubin (G) 421 Glucose
ALP (G) 463 Ketones
Cholesterol (G) 432 Bilirubin
Triglycerides (G) 453 Blood
Albumin (G) 416 SEDIMENT
Total protein (G) 448
Creatinine (G) 433
WBC /hpf
Sodium (G) 450
Potassium (G) 444
RBC /hpf
Chloride (G) 430
Calcium (G) 425
Bacteria /hpf
Magnesium (G) 440
Phosphorus (G) 442
Sperm /hpf
TCO2 (G) 429
CKpre (G) 465
Casts /lpf
CKpost (G) 465 Epithelial cells /lpf
Ammonia (G) 418 Please call
lab prior to submitting
Bile acids (R) 536
IgG Eq/Cam (G) 349
Crystals
IgG Bov (G) 538
For all other tests, please use
special studies form
Comments
√ Therapeutic Drugs
Gentamycinpeak (G) 593 Urgent 582
Gentamycintrough (G) 593 Stat 580
Amikacinpeak (G) 594
R, Red top; L, Lavender top; G,
Amikacintrough (G) 594
Green top; B, Blue top; DB, Dark
Digoxin (G) 513
blue top
Phenobarbital (G) 537 Fax to:
Quinidine (G) 522
Lidocaine (G) 592
LAB/BILLING COPY

Test sample requirement codes:
L – Lavender (or purple) top vacutainer (EDTA anticoagulant)
B – Light blue top vacutainer (sodium citrate anticoagulant)
G – Green top vacutainer (heparin anticoagulant)
Gray – Gray top vacutainer (sodium fluoride glycolysis inhibitor)
R – Red top vacutainer (serum)
DB – Dark blue for FDP testing tubes can be picked up in the lab
Before drawing the blood, please call the lab to make an appointment for ammonia testing.
Light blue top vacutainers for coagulation testing must be filled properly for accurate results.
Please label all gentamicin, amikacin, and glucose tolerance samples with the time of collection.
Sample Type (from the front) refers to CSF, peritoneal, urine, feces, semen, milk, etc.
Flex Pick 4 refers to a special cost discount on any four tests you order. Check the box next to
the “Flex Pick 4” (on the front) and check the boxes next to the four chemistry tests you
would like to order.
If you would like a to request a test and don’t see it on our form, please contact the lab for
availability and sample requirements.
Buffy coat and slide evaluations are performed by the clinical pathologist.