Patient Intake Form: #6
Thomas Lee Abshier, ND
Phone: 503 255 9500,
Fax: 503 255 1888,
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 ***
Uric Acid $6.00 ***
Phosphorus $12.00 ***
ESR - Sedimentation Rate $ 12.00 ***
Liver panel: $39.00 ***
LDH - Lactose Dehydrogenase
Direct bilirubin if Total bilirubin = >1.3
Lipids: $39.00 ***
Heart Risk Panel: $149.00 (Genova Diagnostics)
Cardio CRP (C Reactive Protein) $45
Lipoprotein (a), Apolipoprotein A1, B, lipid panel
Anemia Panel: $48.00
Iron - serum
TIBC - Total Iron Binding Content
Blood Sugar Panel:
Hemoglobin A1C: $30.00
GITT (Glucose Insulin Tolerance test: 3 hour) $104.00
CBC Complete Blood Count: ***
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 Platelet volume
T4 total $35.00 ***
Free T4 $35.00
Extended Thyroid Panel:
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
Male & Female Hormone Panel:
Free Testosterone $85.00
Total Testosterone $85.00
DHEA Sulfate (serum): $70.00
Cortisol AM (serum):
Lymphocyte subset panel: $340.00
CD 3 All T cells, CD 4 Helper cells, CD 8 Suppressor cells, CD 19 B Cells, NK cells (CD 56/57)
Adrenal stress Index: $99.00
Cortisol, 4 samples over full day
DHEA (from average of samples)
GI Health Panels:
Bacteria, Fungi, Parasites, enzymes, Gluten, food antibodies, SIGA, inflammation
Steroid Panel: $250.00
Full spectrum average of steroid hormones over 24 hour period.
Adrenal hormones (Cortisol and metabolites)
Sex Hormones and metabolites (Testosterone, Estrogen, Progesterone)
Food Allergy Panels:
MRT: $350.00 (blood draw, kit, 150 foods, WBC reactivity to food)
ALCAT: $320.00 (blood draw, kit, 150 foods, WBC rxn to food)
Urinary Neurotransmitter Test: $113.00
Epinephrine, Norepinephrine, Dopamine, Serotonin, GABA Phenylethylalanine
Urine Toxic Metal Assay: $58.00
plus challenge/chelating agent: Zeolite, EDTA, DMSA, DMPS)
Chronic Fatigue Assay: $1000.00 +/-
Assay of viruses and blood enzymes related to viral infection correlated to Chronic Fatigue Syndrome
Urine Organic Assay: $250.00
Amino Acid Assay:
40 amino acids
Candida Antibodies and Antigen Complex: $70